ovarian biomarkers in oi

43
Sandro C. Esteves, MD, PhD Director, ANDROFERT Andrology & Human Reproduction Clinic Campinas, Brazil Ovarian Biomarkers in Ovulation Induction XVIII Annual Ob-Gyn Conference, Kuwait 2013

Upload: sandro-esteves

Post on 07-May-2015

642 views

Category:

Health & Medicine


0 download

TRANSCRIPT

Page 1: Ovarian Biomarkers in OI

Sandro C. Esteves, MD, PhD Director, ANDROFERT

Andrology & Human Reproduction Clinic Campinas, Brazil

Ovarian Biomarkers in Ovulation Induction

XVIII Annual Ob-Gyn Conference, Kuwait 2013

Page 2: Ovarian Biomarkers in OI

Individualization of Controlled Ovarian

Stimulation (iCOS)

Optimal Endometrial Receptivity

Maximize beneficial effects of

treatment

Minimize complications

and risks

Central Paradigm

High-quality Gametes and

Embryos

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 2 2013 DECEMBER

ANDROFERT

Page 3: Ovarian Biomarkers in OI

Know the best biomarkers

Understand how they work

How to use biomarkers in Ovulation Induction

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 3 2013 DECEMBER

ANDROFERT

Page 4: Ovarian Biomarkers in OI

http://www.androfert.com.br/review

Ovarian Biomarkers in Ovulation Induction

Esteves SC – Kuwait’s XVIII Annual Ob-Gyn Conference, 2013

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 4 2013 DECEMBER

ANDROFERT

Page 5: Ovarian Biomarkers in OI

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 5 2013 DECEMBER

ANDROFERT

Why Predict Ovarian Response in OI?

Avoid over-aggressive stimulation in ‘true’ high responders Avoid over-conservative stimulation in ‘false’ high responders Ex

cess

ive

Ovar

ian

Resp

onse

Avoid over-conservative stimulation in ‘true’ DOR Avoid over-aggressive stimulation in ‘false’ DOR

Dim

inis

hed

Ovar

ian

Rese

rve

(DOR

)

Page 6: Ovarian Biomarkers in OI

For P

atie

nts

• Poor or Negligible Response • Cycle cancellation • Egg donation or adoption

• Chances of Pregnancy and Live Birth

Realistic Prognosis

Prediction of Ovarian Response in OI

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 6 2013 DECEMBER

ANDROFERT

Page 7: Ovarian Biomarkers in OI

Know the Biomarkers Hormonal Biomarkers FSH, Clomiphene citrate challenge test, Inhibin-B, Anti-Mullerian Hormone (AMH)

Functional Biomarkers Antral Follicle Count (AFC) Genetic Biomarkers Single Nucleotide Polymorphisms for FSH, LH, E2 and AMH receptor genes

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 7 2013 DECEMBER

ANDROFERT

Page 8: Ovarian Biomarkers in OI

A Valid Biomarker Should be Highly Sensitive and Highly Specific

Esteves, 8

+

-

+ -

Bio

mar

ker T

est R

esul

t

Diminished or Excessive Ovarian Response

Adapted from: ASRM Practice Committee, Fertil Steril 2012;98:147

False Positive

(B)

False Negative

(C)

True Negative

(D)

True Positive

(A)

Sensitivity (A/A+C)

Specificity (D/B+D)

Predictive Value (PPV=A/A+B; NPV=D/C+D)

Accuracy (A+D/A+B+C+D)

Page 9: Ovarian Biomarkers in OI

Who is Who Before OI Evidence Level 1a

Esteves, 9

Page 10: Ovarian Biomarkers in OI

Population Cut-off Sensitivity Specificity Accuracy

AMH*ng/mL

High-responder1 2.1 85% 79% 0.82

Poor responder2 0.82 76% 86% 0.88

*Beckman-Couter generation II assay; 1>20 oocytes retrieved; 2≤4 oocytes retrieved

Biomarkers in OI

In a group of 131 women undergoing conventional COS after pituitary down-regulation for IVF:

Leão RBF, Nakano FY, Esteves SC. #O-51: ASRM 2013

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 10 2013 DECEMBER

ANDROFERT

Page 11: Ovarian Biomarkers in OI

Esteves, 11

Evidence Level 1a

AMH and AFC are not accurate for pregnancy prediction

Broer et al. Fertil Steril 2009 ; Broer et al. Hum Reprod Update, 17:46; 2011

Page 12: Ovarian Biomarkers in OI

How AMH and AFC Work

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 12 2013 DECEMBER

ANDROFERT

Page 13: Ovarian Biomarkers in OI

Esteves, 13

La Marca et al, Hum Reprod 2009;24:2264; Fleming et al, Fertil Steril 2012;98:1097; Broekmans et al. Fertil Steril, 2010; 94:1044-51; Scheffer et al. Hum Reprod 2003;18:700

.

Reflect No. pre-antral and small antral follicles

(≤4-8mm)

AMH

AF

C 2D-TVUS early follicular phase 2-10 mm (mean diameter)

No. AF at a given time that can be stimulated by medication

Page 14: Ovarian Biomarkers in OI

Esteves, 14

AMH

Low Inter-cycle Fluctuations (Fanchin et al, Hum Reprod 2005;20:923)

Low Intra-cycle Fluctuations (Hehenkamp et al. JCEM 2006;91:4057)

ICC: 0.89; 95% IC: 0.83–0.94 ICC: 0.55; 95% IC: 0.39–0.71

Max. Variation: 17.4% Max. Variation: 108%

Can be assessed at any cycle day with a single measurement

Page 15: Ovarian Biomarkers in OI

Esteves, 15

Serum Levels: Peak at age 25 and decrease with aging Early marker of diminished ovarian reserve

Non-growing follicles (NGF) recruited per month

Kelsey et al. Mol Hum Reprod 2012;18:79

AMH

Page 16: Ovarian Biomarkers in OI

Esteves, 16

AMH

*DSL assay; 1>20 oocytes retrieved; 2≤5 oocytes retrieved; Conversion: ng/mL to pmol/L = value in ng/mL X7.14

Cut-off point 3.5 ng/mL* (Nardo et al, Fertil Steril 2009;92:1586)

Ø  High sensitivity (88%), specificity (70%) and accuracy (0.81) to predict excessive response1

Cut-off point 1.4 ng/mL* (Kwee et al, Fertil Steril 2008;90:737)

Ø  High sensitivity (76%) and specificity (86%) for DOR2

Caution to apply AMH cut-off points! Make sure the assay you rely on is the same used in the reference population

Accurate to Predict Ovarian Response

Page 17: Ovarian Biomarkers in OI

Esteves, 17

AM

H

Fleming et al. RBM online 2013;26:130; Nelson SM. Fertil Steril. 2013 Jan 8; Nelson & La Marca. RBM online 2011;23:411;

ELISA assays with different performances:

DSL and Immunotech Beckman-Couter gen II (AB DSL + Curves Im.)

Fully automated ELISA (to be released)

Lack international standardization and EQC

Sample instability; measured levels altered by handling

Collection in EDTA Storage at room temperature (up to 40% increase)

No separation of serum from blood before postage

Page 18: Ovarian Biomarkers in OI

Esteves, 18

AFC

Moderate to Low Inter-cycle Fluctuations van Disseldorp et al, Hum Reprod 2010;25:221

ICC: 0.71 (95% CI: 0.63–0.77); 29% individual cycle

variation

High Inter- and Intra-observer Reproducibility Scheffer et al. Ultrasound Obstet Gynecol 2002;20:270

Page 19: Ovarian Biomarkers in OI

Esteves, 19

AFC

Cut-off point of 4 Bancsi et al, Fertil Steril 2002;77:328

Moderate sensitivity (61%) and High specificity (88%) and to predict DOR2

Cut-off point of 14 Kwee et al, Fertil Steril 2008;90:737

High sensitivity (81%) and specificity (89%) to predict excessive response1

1>20 oocytes retrieved in conventional COS; 2≤4 oocytes retrieved

Caution to Apply Cut-off Points to Predict No. of Oocytes to be Retrieved

For any given AFC there is a potential oocyte yield, but it can be altered by the stimulation strategy

Accurate to Predict Ovarian Response

Page 20: Ovarian Biomarkers in OI

Esteves, 20

AFC

1Nelson SM. Fertil Steril. 2013 Jan 8; 2Broekmans et al., Fertil Steril, 2010; 94(3):1044-51;

3Raine-Fenning et al., Fertil Steril 2009;91:1469.

Lack of standardization1

• Inclusion criteria for antral follicles Ø  e.g., 2–5 mm or 2–10 mm

• Method for counting and measuring follicles

• Variable scanning techniques • Image optimization Improved standardization

proposed2

Three-dimensional automated follicular tracking3

• Reduce intra- and inter-observer variability • Requires offline analysis • Costly

Page 21: Ovarian Biomarkers in OI

How to Use AMH and AFC in OI

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 21 2013 DECEMBER

ANDROFERT

Page 22: Ovarian Biomarkers in OI

Low-starting FSH dose (150 UI)

AMH (ng/mL) >2.1¶ GnRH Agonist

(n=148) GnRH

Antagonist (n=34)

Days of Stimulation 13 (12-14) 9 (8-11)*

No. Oocytes retrieved (n) 14 (10-19) 10 (8.5-13.5)*

OHSS requiring hospitalization 20 (13.9%) 0 (0%)*

Cancellation 4 (2.7%) 1 (2.9%) CPR per transfer 40.1% 63.6%*

¶DSL assay; Adapted from Nelson SM et al . Anti-Müllerian hormone-based approach to controlled ovarian stimulation for assisted conception. Hum Reprod. 2009; 24(4):867-75.

*P ≤ 0.01

Esteves, 22

Biomarkers for iCOS in High Responders

Evidence Level 2b

Page 23: Ovarian Biomarkers in OI

Evidence Level 1a

Esteves, 23

GnRH Antagonists in High Responders

9 RCT; 966 PCOS women GnRH Antagonist X Agonist

Weight Mean Difference (WMD)1; Relative Risk (RR)2

Duration of OS -0.74 (95% CI: -1.12; -0.36)1

Gonadotropin dose -0.28 (95% CI: -0.43; -0.13)1

Oocytes retrieved 0.01 (95% CI: -0.24; 0.26)1

Risk of OHSS (Moderate & Severe) 20% vs 32%

0.59 (95% CI: 0.45-0.76)2

Clinical PR 1.01 (95% CI: 0.88; 1.15)2

Miscarriage rate 0.79 (95% CI: 0.49; 1.28)2

Pundir J et al. RBM Online 2012; 24:6-22.

~40% reduction in moderate/severe OHSS by using antagonists rather than agonists

Page 24: Ovarian Biomarkers in OI

4 RCT; 2377 pts. OR [95% CI]

Clinical PR, Miscarriage, LBR Not different

Risk of OHSS 1.29 (0.78; 2.26)

Cancellation 5.67 (1.07; 30.13)*

*p=0.04; risk of OHSS

GnRH Antagonist Protocol with Long-acting recFSH vs recFSH

Mahmoud Youssef et al. van Fertil Steril 2012; 97(4): 876-85; Pouwer AW et al. Cochrane Database Syst Rev 2012; 6: CD009577.

Esteves, 24

Page 25: Ovarian Biomarkers in OI

Older patients (≥35 years)

Poor responders

Slow/Hypo-responders

Deeply suppressed endogenous LH

Marrs et al. Reprod Biomed Online 2004;8:175;Mochtar MH, Cochrane Database, 2007; Alviggi, et al. RBMOnline 2009; De Placido et al. Clin Endocrinol (Oxf) 2004;60:637

Up to 45% of Infertility Patients in ART

Biomarkers for iCOS in Poor Responders

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 25 2013 DECEMBER

ANDROFERT

Page 26: Ovarian Biomarkers in OI

Impaired Oocyte Quality

Reduced Fertilization Rate

Reduced Embryo Quality

Increased Miscarriage Rates

Westergaard et al., 2000; Esposito et al., 2001; Humaidan et al., 2002

Ovarian Aging

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 26 2013 DECEMBER

ANDROFERT

Page 27: Ovarian Biomarkers in OI

• Normal androgen and estrogen biosynthesis • Normal follicular growth and development • Normal oocyte maturation N

orm

al

LH “Window” Concept

Reduced ovarian

paracrine activity

Hurwitz & Santoro 2004

Androgen secretory capacity reduced

•  Piltonen et al., 2003

Decreased numbers of functional

LH receptors

•  Vihko et al. 1996

Reduced LH bioactivity

•  Mitchell et al. 1995; Marama et al 1984

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 27 2013 DECEMBER

ANDROFERT

Page 28: Ovarian Biomarkers in OI

LH Supplementation in DOR

Regimen Outcome Effect on Pregnancy

Mochtar et al, 2007 3 RCT (N=310) Poor responders

r-hFSH+rLH vs.

r-hFSH alone*OPR OR: 1.85

(95% CI: 1.10; 3.11)

Bosdou et al, 2012 7 RCT (N= 603) Poor responders

r-hFSH+rLH vs.

r-hFSH alone*

CPR

LBR (only 1 RCT)

RD: +6%, (95% CI: -0.3; +13.0)

RD: +19% (95% CI: +1.0; +36.0%)

Hill et al, 2012 7 RCT (N=902) Women advanced age ≥35 yrs.

r-hFSH+rLH vs.

r-hFSH alone

CPR

OR: 1.37 (95% CI: 1.03; 1.83)

*long GnRH-a protocol; OR=odds-ratio; RD=risk difference

Mochtar MH et al. Cochrane Database Syst Rev. 2007;2:CD005070; Bosdou JK et al, Hum Reprod Update 2012; 8(2):127-45. Hill MJ et al. Fertil Steril 2012; 97:1108-4. Esteves, 28

Level 1a

Page 29: Ovarian Biomarkers in OI

Action of LH at the follicular level in a dose dependent manner increases androgen production; Androgens are later aromatized to estrogens and may help restore the follicular milieu;

LH has also a direct positive effect on final follicular maturation;

Altogether, positive effect in oocyte quality and, therefore, embryo quality and implantation.

Rationale of LH supplementation

Esteves, 29

Page 30: Ovarian Biomarkers in OI

*derives from hCG

Purity (LH content)

hCG content (IU/vial)

LH activity (IU/vial)

Specific activity (LH/mg protein)

>99% 0 75 22,000 IU

3% ~70 75* ≥ 60 IU

Sources of LH Activity

Rec-hLH

hMG-HP*

Adapted from ASRM Practice Committee. Fertil Steril. 2008; 90:S13-20.

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 30 2013 DECEMBER

ANDROFERT

Page 31: Ovarian Biomarkers in OI

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 31 2013 DECEMBER

ANDROFERT

Beta unit

Carboxyl terminal segment

Longer in hCG;

(Higher receptor affinity)

Absent in LH and present in hCG

(Longer Half-life)

Sources of LH Activity Sources of LH Activity

hCG

LH

Page 32: Ovarian Biomarkers in OI

Grondal et al. 2009: GCs gene expression in pts. treated with hMG and rec-hFSH q  Lower expression of LH/hCG receptor

gene and other genes involved in steroids biosynthesis in hMG group

Down-regulation of receptors owed to constant ligand exposure to hCG

(Menon et al. 2004) CYP11A activity decreased by 2.4 fold

Lower steroids synthesis and P levels q  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

Sources of LH Activity

Esteves, 32

r-FS

H

hMG

Page 33: Ovarian Biomarkers in OI

Sources of LH Activity

19 14 14

31 26 25

0 5

10 15 20 25 30 35

Fixed 2:1 r-hFSH (150IU)/r-hLH

(75IU)

HMG rec-hFSH + HMG

Duration of Stimulation (days) Mean No. oocytes retrieved IR (%)

CPR per transfer (%)

Buhler KF, Fisher R. Gynecol Endocrinol 2011;1-6.

Matched case-control study; N=4,719 IVF pts.

P=0.02

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 33 2013 DECEMBER

ANDROFERT

Page 34: Ovarian Biomarkers in OI

Esteves, 34

Individualization of OI with AMH

High Responders

AMH >2.1

Poor Responders

AMH ≤ 0.82

rec-hFSH FbM 112.5 to 150 IU daily + GnRH antagonist

rec-hFSH FbM + 75 IU rec-hLH + GnRH antagonist

• Total daily dose: 262.5 to 375 IU

AMH cut-off points used to individualize COS in 118 women undergoing IVF; Outcome compared with a group of 131 women who received conventional stimulation

Leão RBF, Nakano FY, Esteves SC. #O-51: ASRM 2013

Page 35: Ovarian Biomarkers in OI

39.3

18.5 14.0

57.0

14.3 14.7

4.8

56.0

0

10

20

30

40

50

60

Observed Excessive

Response (%)

Oocytes retrieved (N)

OHSS (%) Pregnancy (%)

cCOS iCOS

1Excessive response: >20 oocytes retrieved; *Pts. received GnRH-a trigger + embryo vitrification; Mild/severe OHSS reported

p=0.03

p=0.04 p=0.38

p=0.92 iCOS Using AMH

High Responders

Leão RBF, Nakano FY, Esteves SC. #O-51: ASRM 2013 Esteves, 35

Page 36: Ovarian Biomarkers in OI

72.0

3.5

45.0

20.0

46.6

4.8

23.3 26.8

0

20

40

60

80

Expected Poor Response (%)

Oocytes retrieved (N)

Cancellation (%) Pregnancy/cycle (%)

cCOS iCOS p=0.02

p=0.03

p=0.06 p=0.51

iCOS Using AMH Poor Responders

Leão RBF, Nakano FY, Esteves SC. #O-51: ASRM 2013

Poor response <5 oocytes retrieved

Esteves, 36

Page 37: Ovarian Biomarkers in OI

AMH and AFC are currently the best biomarkers to predict ovarian response to COS.

AMH and AFC are direct biomarkers of ovarian reserve. Both markers have similar accuracy to predict who is at risk of excessive and poor response in COS.

After identifying ‘Who is Who’, mild stimulation and GnRH antagonists in pts. at risk of excessive response, and rec-hLH supplementation in DOR, maximize treatment benefits and minimize risks.

Take Home Messages

ANDROFERT androfert.com.br

ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 37 2013 DECEMBER

ANDROFERT

Page 38: Ovarian Biomarkers in OI

Thank you

Page 39: Ovarian Biomarkers in OI

Esteves, 39

1Excessive response: >20 oocytes retrieved; 2Poor response: <5 oocytes retrieved; *Pts. received GnRH-a trigger + embryo vitrification; No severe OHSS reported

Response to COS Conventional COS

(n=131) iCOS

(n=118) P

value

Excessive1

Oocytes retrieved OHSS

Pregnancy

39.3% 18.5 ± 6.7

14.3% 57.1%

14.3% 14.7± 6.2

4.8%* 55.6%

0.03 0.04 0.38 0.92

Poor2

Oocytes retrieved Cancellation

Pregnancy/ET

72.0% 3.5 ± 3.1

45.0% 20.0%

46.6% 4.8 ± 3.5

23.3% 26.8%

0.02 0.03 0.06 0.51

iCOS Using AMH

Page 40: Ovarian Biomarkers in OI

Progesterone Rise What we have learned…

Number of oocytes Estradiol levels on hCG day 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

P levels not associated with oocyte and embryo quality, nor with fertilization and cleavage rates

Esteves, 40 ANDROFERT, Referral Center for Male Reproduction

Page 41: Ovarian Biomarkers in OI

LH

FSH

LH

Esteves, 41

No CYP17

Page 42: Ovarian Biomarkers in OI

Esteves, 42 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

Progesterone thresholds affecting PR controversial

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

Page 43: Ovarian Biomarkers in OI

Esteves, 43 ANDROFERT, Referral Center for Male Reproduction

Griesinger et al, 2013 (6 RCT, N=1866; Antagonist cycles)

P4 cut-off: 1.5 ng/mL P4 rise related to ovarian response:

Low-responder: 4.5% High-responder: 19% Overall: 8.4%

OPR not impaired in high responders with P elevation

Effect of progesterone levels on day of hCG administration on pregnancy

Griesinger et al. Fertil Steril 2013

Ongoing PR: OR = 0.55 (0.37–0.81)