The Spectrum of Ovarian “Aging”: From birth to menopause

Etiologies and treatment strategies

Amber R. Cooper MD, MSCI

Disclosures

• No relevant financial disclosures

Objectives

• Understand the decline in oocyte quality and quantity across a woman’s lifespan

• Differentiate between normal and pathologic ovarian “aging”

• Discuss potential treatment strategies for women with ovarian “aging” who desire pregnancy

The Ovary

• The human enigma

• Structure discovered early, normal and abnormal function remain elusive

• “Ovarian Aging”

• Natural

• Pathogenic

Salvador Dali, 1929

Natural Ovarian Aging• Differs from somatic aging (and testicular

aging)

• We tend to focus on the oocyte…but the follicular unit may be equally important

• Age at menopause has a high heritable component

• Twin and Mother/daughter studies

• Individual variability exists in initial follicle pool, rate of depletion, and age at menopause

Clinical Spectrum of Natural & Pathologic

Ovarian Aging

Fertile

Recurrent pregnancy loss

Infertility Ovarian aging

Diminished ovarian reserve

Primary ovarian insufficiencyEarly menopauseMenopause

Oocyte Pool

Modified from: Speroff. Clinical Gynecologic Endocrinology and Infertility. 7th ed.

Fixed Pool; peaks at 5-6 mill

80% lost by birth

500,000 1,00025,000

Quantity vs. Quality

Declining Oocyte Quantity

Originally thought to be a simple exponential decline in number (in the reproductive years)

Mattison DR. Dixon (ed). Reprod Toxicol 1985

Block E. Acta Anat 1952

Most ultimately believed bi-exponential model of declineConcept of critical mass (25,000)Magical age of “37-37.5”

Faddy MJ Hum Reprod 1992

In reality, more like a constant increasing rate of loss than a magical number

Hansen K R et al. Hum Reprod 2008

Oocyte Quality = Age

(and maybe a little AMH?)

The Impact of Female Age Alone

(vs. Behavior)

ACOG and ASRM Practice Guideline. Fertil Steril 2008

Marital fertility rates by 5-year age groups in specific populations

The Impact of Female Age Alone

• French Study of Female Fecundity• 2193 nulliparous women with azoospermic

men• Donor Inseminations in 11 centers• Cumulative success rates after 12 cycles

• 30 years of age or younger: 74%• 31-35 years old: 61%• Over 35 years: 54%

Schwartz D, Mayaux MJ. NEJM 1982; 306 (7): 404.

Why does fertility decline with age?

Ovarian aging ***

Increased aneuploidy ***

Endometrial aging

Behavioral changes

Increased incidences of other infertility-related conditions (fibroids, tubal disease, endometriosis, etc)

Increased exposure to iatrogenic and environmental cytotoxic agents

Normal Reproductive Aging

Regular menses does NOT imply normal fertility

Societal and Behavioral Shifts…

Demand for

“Female Fertility Testing”

Reproductive Delay

Ovarian Aging

Advancing Technology

The term “ovarian reserve”

“Describes a woman’s reproductive potential with respect to ovarian follicle number and oocyte quality”

ASRM Practice Committee Aging and Infertility in Women 2006

“A term that is used to determine the capacity of the ovary to provide eggs that are capable of fertilization resulting in a healthy and successful pregnancy”

Wikipedia

Measuring ‘Ovarian Reserve’

Term coined to predict oocyte yield and outcomes in IVF; Individualize therapies; Not perfect

Serum assaysFSH, Estradiol, Inhibin BAnti-Müllerian Hormone (AMH) US measurementsAntral follicle count (AFC)Ovarian volume

Dynamic Tests

Which population are we talking about?

All females

Women Delaying

Conception

Infertility

IVF

Antimüllerian Hormone: AMH• Hot topic of ovarian reserve screens

• Produced by granulosa cells of 2-6 mm follicles

• indirectly reflecting remaining primordial pool

• Seen as the “recruitment regulator”

• Diminishes with age; often undetectable 5+ years before menopause

• Not cycle day specific

• Beware of assay, storage and handling variability

• Elevated in PCOS patients

• Influenced by BMI and hormonal contraception

Is AMH Nonlinear?

Anti-müllerian hormone (AMH)

nomogram, based on a quadraticmodel of

log(AMH) on age

Nelson. AMH age nomogram. Fertil Steril 2010.

Antral follicle count (AFC)

Widely used ultrasound measure of ovarian reserveTransvaginal, early follicular phase best

studied

Probably the best predictor of ovarian response to stimulationThresholds for a low AFC definition vary

Most use the combined number of 2-9 or 2-10 mm follicles on each ovary

There is an age-related decline in AFC

High AFC may have predictive value also

10 y/o girl

Abnormal ovarian aging…

Ovarian Insufficiency

Iatrogenic (Surgery, toxic therapies

Environmental(EDC, tobacco)

Genetic/Epigenetic• Nuclear• mtDNA

Autoimmune

Idiopathic

•Probable mechanisms• Reduced oocyte pool• Accelerated follicular atresia• Alterations in follicular processes

** The oocyte is vulnerable in its state of arrest in meiosis I**• Cumulative exposure ??

Phenotypes of Ovarian Insufficiency

Cooper AR, Covington SN, Nelson, LM. Primary ovarian insufficiency (POI). In: Santoro N, et. al. ed. Amenorrhea: A Case-based clinical guide. Humana Press, c2011.

Nelson LM. Clinical practice. Primary ovarian insufficiency. N Engl J Med 2009;360:606-14.

DOR

POI

Primary Ovarian Insufficiency (POI)

Premature ovarian failure vs Primary ovarian insufficiency

Not a dichotomous state Much more like a continuum Unlike natural menopause-

Ovarian function is unpredictable5-10% may still conceive

Accelerated physiologic aging or pathologic reduction through other mechanisms?

Spontaneous POI 90+% remain idiopathic Other etiologies have been proposed

2% FMR1 premutation (0.7% early menopause; 0.4% controls)

4% possible steroidogenic cell autoimmune mechanism

Abnormal karyotypes

Primary amenorrhea (~10% POI): 50-60%

Secondary amenorrhea: 5-15% Other rare genetic mechanisms (e.g. WRN, GALT, FOXL2)

10-20% may have familial component Associated with autoimmune diseases (thyroid and adrenal)

Nelson L. NEJM 2009van Kasteren et al Hum Reprod 1999Murray et at. Genet Med 2014; Voorhuis Hum Reprod 2013

“Diminished ovarian reserve” (DOR)

• Less severe phenotype than POI or different pathologic process?

• No clear consensus definition despite hundreds of publications

Ferraretti et al. Hum Reprod 2011

ESHRE: Defines the poor responder

Need 2 of 3:

(i) advanced maternal age or any other risk factor for Poor Ovarian Reserve

(ii) a previous POR

(iii) an abnormal ovarian reserve test (ORT).

Using a stricter definition helps create a more crisp and reliable results from research

Hum Reprod. 2011; The Bologna criteria

Ovarian “responsiveness” vs

“aging”

• Could reduced ovarian “responsiveness” be part of the aging process?

• Could glycosylation of FSH play a role?

• Or is the ovary itself the master regulator of the aging process?

Jiang et al. JCEM 2015

X chromosome and Ovarian Aging

Turner syndrome-ovarian dysgenesis in 85-90%

Critical regionsXp11.2-22.1Xq26-q28; Xq13-q21

Deletions at/distal to Xq21 usually secondary amenorrhea/POI

Smaller deletions Xq27-q28 may just have early menopause

Several other candidate genes

Adapted from Spatz et al. Nature Reviews 2004

Rizzolio et al Hum Reprod 2006 and 2007; Spatz et al Nature Rev 2004

Meiosis is critical to oocyte development

• Homologue pairing and recombination is vital.

• Probably-pairing along the whole X chromosomes in order to make viable oocytes…

• Examples:• The mule• The seedless

watermelonAdapted from Marston and Amon, Nature Reviews Molec Cell Bio 2005

Genetics of Ovarian Aging

Polygenic and MultifactorialComplex trait

• Genetic/Heritability• Environmental

A number of genes throughout the genome have a suggested role in ovarian function

Past POI studies identified some candidate genes through FISH/PCR; few through array, linkage, or GWAS

• All small• Lack power to detect genes with smaller effect sizes• Most focus on common variants not rare

The Environment and Ovarian Aging

• Smoking

• 1 to 1.5 years earlier menopause

• Obesity?

• Endocrine disrupting chemicals

• Our recent study found an association between 15 EDCs and earlier menopause; 2-4 years earlier

• 9 PCBs, 3 pesticides, 1 dioxin and 2 phthalates

• Cumulative exposure???Grindler N, Allsworth J, Macones G, Kannan K, Roehl K, Cooper AR (2015) PLOS One

Cytotoxic Therapies and ovarian damage

May be temporary

The majority of past studies focus on the risk of POF/POI or azoospermia

Many women have diminished ovarian reserve despite normal menses

Best estimates-risk of infertility40-80% in females30-75% in malesDepends on age, cancer site, treatment type and dose and

pretreatment fertilityLee S et al. J Clin Oncol 2006.; Schover L et al. Cancer 1999.; Sonmezer M

and Oktay. Oncologist 2006.; Wallace W et al. Lancet Oncol 2005.

ASCO guide: Permanent amenorrhea risk

Lee S et al. J Clin Oncol 2006.

Treatment effects on fertility

Ovarian reserve biomarkers have allowed for further investigation in survivors

Women with childhood cancer therapies show diminished ovarian reserve despite regular cycles

AMH and AFC most promising markers

Bath L et al. Hum Reprod 2003.Larsen et al. Hum Reprod 2003.

AMH in cancer survivors:Dose-dependent decline

Gracia et al. Fertil Steril 2012.

Can we intervene?

Intervention vs Prevention

• Awareness is key!!!

• Understanding the etiologies is the first step towards prevention

• Need for better diagnostic tests to intervene prior to cessation of function

•Fertility preservation options at an earlier age

Nutrition and Ovarian Aging

• Diet• Composition (fat/carbs)• Omega 6:3 fats ratio• Caffeine• Antioxidants

• Obesity?• Alcohol, Tobacco• Exercise/Relaxation• Supplements• Environmental exposures…

Oxidative stress• Reproductive aging associated with oxidative

stress

• Sources vary: illness, inflammation, smoking, alcohol, other processes, ?obesity/diet

• May damage an already fragile aging oocyte or alter the follicular quality

• In turn may affect fertilization and embryo growth processes

• Antioxidants: Vitamins (A, C, E), nuts/seeds, fruits/vegetables (5+ servings), herbs (ginger, tumeric, cloves, cinnamon, oregano)

• Recent Cochrane review would suggest data still lacking and poor

DHEA• Metabolic intermediate Androgen

Estrogen

• Intrafollicular IGF-1 (potentiates gonadotropins?)

• Own biologic affect?

• Possibly improves oocyte quality, LBR in poor responders

• DHEA(S) levels decline with age

• JCEM 2013 RCT (China): 16 weeks 25 mg TID in POI patients (vs placebo), AMH primary outcome

• Kara 2014: DHEA 12 weeks RCT IVF ICSI showed no increased preg rate.

Casson 2005, Wiser 2010, Yeung et al 2013 JCEM; Kara 2014Eur J Ostet Gynecol Reprod Biol

Co-enzyme Q10• Important for cell energetics

(mitochondrial)

• Antioxidant

• Past “youth drug” used in many subspecialties

• Oocyte energetics Embryo quality

• Study: Patients with more CoQ10 in follicular fluid at the time of IVF-more mature oocytes and better quality embryos (Turi et al; 2012)

• Less aneuploidy too? (Casper’s data)

• Best estimate: 600 mg/day

Oocyte/Follicle development(not really a “monthly”

process)

Antral follicle

recruitment

Gougeon. Hum Reprod 1986

Other supplements

• Myo-inositol (B-complex vitamin)• Myo + Melatonin antioxidant combo?

• L-arginine amino acid? Mixed data• Vitamin D deficiencies and IVF?• Selenium?• Media supplements or patient diet?

• Most stopped at retrieval, Duration needed for use to see effect unclear

Ovarian aging and Tailored IVF Protocols

• Priming with OCPs?

• Less drug and days of FSH?• Priming with Estradiol?

• Decreased cancellation? More oocytes? Increased PR?

• Priming with Testosterone?• Increased sensitivity to FSH, oocytes,

IR, PR, LBR?

Ovarian aging and Tailored IVF Protocols

• Stimulation regimen

• Antagonist better? Or most equal?

• “Mild” or “Mini” IVF-cost effective and patient friendly but data on benefit still lacking

• Adding GH? …May be value; meta-analyses show co-treatment improves outcome (PR/LBR); ? Quality or endometrial improvement rather than response

Ovarian aging and Tailored IVF Protocols

• Oocyte retrieval

• Delaying hCG trigger 0.5-1 hour?

• FSH “boost” with hCG ?

• Aneuploid screening?

• Time-lapse photography?

Reichman DE et al. Fertil Steril 2011

Lamb JD et al. Fertil Steril 2011

Future Intervention?

Experimental options:

Ovarian fragmentation / In vitro activation study; Kawamura et al

Ovascience technology Augment; Ovature/OvaPrime

“Reproductive Age” =Genetics

(Epigenetics)

TranscriptomeEnvironment

AGE +

Ovarian Health

“Ovarian Age” =AGE + Ovarian Reserve

(oocyte quantity)

THANK YOU!