fertility in midlife women
TRANSCRIPT
02.11.2014
1
Fertility in midlife women
Tevfik Yoldemir MD, BBA, MSc
Associate Professor
Marmara University, School of Medicine
Department of Obstetrics and Gynecology
Division of Reproductive Medicine
Istanbul, Turkey
Follicle depletion
doi:10.1016/j.ijgo.2011.11.002
Ovarian response predictors
Am J Obstet Gynecol 2008;199:202.e1-202.e8.
Treatment alternatives
http://dx.doi.org/10.1016/j.fertnstert.2012.11.051
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Poor ovarian response
Two out of three of the following criteria were essential
in order to classify a patient as poor ovarian
responder:
(i) advanced maternal age (≥40 years) or any other risk
factor for poor ovarian response;
(ii) a poor ovarian response (≤3 oocytes with a
conventional stimulation protocol); or
(iii) an abnormal ovarian reserve test (AFC<7 follicles or
AMH<1.1 ng/ml).
Hum Reprod 2011;26:1616–1624.
Prediction of POR
RBMOnline - Vol 17. No 4. 2008 508-514
doi:10.1016/j.fertnstert.2007.12.077 doi:10.1016/j.fertnstert.2007.12.077
doi:10.1016/j.fertnstert.2007.12.077
POR- stop vs non-stop long GnRHa
doi:10.1016/j.fertnstert.2007.12.077
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POR- GnRH anta vs GnRH agon
doi:10.1016/j.fertnstert.2007.12.077
GnRH anta vs GnRH agonist
http://dx.doi.org/10.1016/j.fertnstert.2013.08.024
Luteal phase Anta vs Microdose flare
doi:10.1016/j.fertnstert.2008.04.024
Luteal phase Anta vs Microdose flare
doi:10.1016/j.fertnstert.2011.01.134
Androgen suppl
doi:10.1016/j.fertnstert.2011.04.083
POR – GH addition
doi:10.1016/j.fertnstert.2007.12.077
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Case 1
• 40 year-old woman
• Nulliparous
• Newly married ( 4 months)
• Cycle length longer than it is used to be
• FSH 14 IU/L
• She is worried about her chances for conception.
• How would you counsel her?
Low responder –before / after ART
doi:10.1016/j.fertnstert.2012.02.012
Low responder
doi:10.1016/j.fertnstert.2012.02.012 doi:10.1016/j.fertnstert.2011.06.072
Case 2
• 39 year-old woman
• Single
• Previous history of LS left endometrioma excision
• AMH 0.8 ng/ml
• Curious about her fertility potential.
• What would you advise her ?
doi:10.1016/j.fertnstert.2011.07.1102
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Predicting POR
doi:10.1016/j.fertnstert.2011.07.1102
AMH
Prediction for POR
doi:10.1016/j.fertnstert.2008.10.042
Women with extremely low (0.4 ng/ml) anti-
Mullerian hormone (AMH) concentrations
doi:10.1016/j.rbmo.2013.09.017
Women with extremely low (0.4 ng/ml) anti-
Mullerian hormone (AMH) concentrations
doi:10.1016/j.rbmo.2013.09.017
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Case 3
• 38 year-old woman
• Nulliparous
• Inhibin B = 50 pg/ml, AFC = 5
• Trying to get pregnant for the last 9 months
• She asks for treatment options?
doi:10.1016/j.fertnstert.2011.07.1102
Inhibin B / D5 Inhibin B
Prediction for POR
doi:10.1016/j.fertnstert.2010.03.009 doi:10.1016/j.fertnstert.2011.07.1102
Basal Inhibin B
Stimulated Inhibin B
Predicting POR
doi:10.1016/j.fertnstert.2011.07.1102
Case 4
• 40 year-old woman
• Had a pelvic scan and was told that her
ovaries “looked lazy”
• She is willing to find out her chances of
conception.
• Which other information would be relevant?
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AFC / AMH- prediction of POR
doi:10.1016/j.fertnstert.2008.10.042
AFC – ovarian response
doi:10.1016/j.fertnstert.2010.03.023
AFC – ovarian response
doi:10.1016/j.fertnstert.2010.03.023
AFC – Implantation R, Pregnancy R
doi:10.1016/j.fertnstert.2010.03.023
AFC
http://dx.doi.org/10.1016/j.fertnstert.2012.05.042
AFC vs AMH
doi:10.1016/j.fertnstert.2007.12.013
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Am J Obstet Gynecol 2008;199:202.e1-202.e8.Am J Obstet Gynecol 2008;199:202.e1-202.e8.
< 4 oocytes retrieved ≥15 oocytes retrieved
Advanced
age fertility
RBMOnline - Vol 19. No 4. 2009 599–603
IVF results >40 yrs (Ng 2007)
Case 5
• 34 year-old woman
• Has started COH for ART; only 3 follicles
developed.
• She wants to know what will happen next?
IUI vs IVF
http://dx.doi.org/10.1016/j.fertnstert.2013.02.049
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IUI vs IVF
http://dx.doi.org/10.1016/j.fertnstert.2013.02.049
IUI vs retrieval
doi:10.1016/j.fertnstert.2009.03.059
Ongoing PR
doi:10.1016/j.fertnstert.2012.03.014
High-responder Normo-responder Poor responderPOR Natural IVF cycles
doi:10.1016/j.fertnstert.2008.07.1765
Conclusions
• Better tailored COH protocols
• Time-lapse markers for better embryo
selection
• Tests (ERA) for the optimization of
endometrial receptivity
• Oocyte / ovarian tissue cryopreservation
http://dx.doi.org/10.1016/j.mam.2013.06.001
Improve ovarian response
http://dx.doi.org/10.1016/j.fertnstert.2012.10.011
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Time-lapse markers used for
clinical outcome predictions
http://dx.doi.org/10.1016/j.fertnstert.2013.01.143
Endometrial receptivity
http://dx.doi.org/10.1016/j.fertnstert.2012.12.005
Thank you for your attention