number of oocytes and progesterone levels in ivf: do they matter?

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


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



...in all age groups

Gonadotropin Preparations and Oocyte Yield


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


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


Quantity vs. Quality

which one come first?

• Oocyte/embryo quality?

• Endometrial receptivity?


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


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


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


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


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


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


More is good, but does it affect

implantation?

• Oocyte/embryo quality?

• Endometrial receptivity?


Effect of progesterone levels on pregnancy in IVF – Do they matter?


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


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


Bosch et al,. Hum Reprod. 2008 ;23(10):2346-51;

Grøndahl ML, et al. Fertil Steril 2009; 91(5): 1820-30.


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


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


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%


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


Cumulative live birth to improve treatment outcome in ART

Pillar #1 – IVF facilities

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


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


Identification of Embryos with Optimal Development Potential


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


Conclusions (1)


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)


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)


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

number of oocytes and progesterone levels in ivf: do they matter?

Health & Medicine