1. IMPART, Dubai 2013
Number of Oocytes and
Progesterone Levels in IVF
Success
Do they matter?
Sandro C. Esteves, MD, PhD
Director, ANDROFERT
Andrology & Human Reproduction Clinic
Campinas, Brazil

2. Number of oocytes and
progesterone levels in IVF success
http://www.androfert.com.br/review
ANDROFERT
ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION
S ESTEVES, 2
2013 DECEMBER
ANDROFERT
androfert.com.br

3. 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

4. Evidence
Level
1a
Predictive factors for pregnancy
in ART
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
Positive
Predictor
van Loendersloot et al. Hum Reprod Update 2010
Esteves, 4
ANDROFERT, Referral Center for Male Reproduction

5. Number of oocytes retrieved and
live birth rates
Observed live birth rate
Predicted live birth rate
45%
number of oocytes that best
optimized LBR was 15
Live birth rate (%)
40%
35%
30%
25%
450,135 IVF cycles
20%
15%
10%
5%
0%
1
Esteves, 5
2
3
4
5
6
7
8
9 10 11 12 13 14 15 20 25 30 35 40
Oocyte number
Sunkara et al. Hum Reprod 2011
ANDROFERT, Referral Center for Male Reproduction

6. ...in all age groups
Esteves, 6
ANDROFERT, Referral Center for Male Reproduction

7. Gonadotropin Preparations
and Oocyte Yield
Esteves, 7
ANDROFERT, Referral Center for Male Reproduction

8. Evidence
Level
1b
RCT and meta-analyses comparing oocyte
yield with different gonadotropins
↑ 1.5 oocytes (GnRH antagonist cycles)
Devroey et al., 2012
No. Oocytes
retrieved higher
with Rec-FSH vs.
hMG, HP-hMG,
and uFSH
↑ 2.1 oocytes (16 RCT; different protocols)
Lehert et al., 2010
↑ 3.1 oocytes (GnRH antagonist cycles)
Bosch et al., 2008
↑ 2.8 oocytes (GnRH agonist cycles)
Hompes et al., 2008
↑ 1.8 oocytes (GnRH agonist cycles)
MERIT Study, 2006
Esteves, 8
ANDROFERT, Referral Center for Male Reproduction

9. It relates to the way the
drug is made, filled and
delivered
Protein content in
solution by mass
(FbM) in rec-FSH
Protein
content
hMG
hMG-HP
Specific
activity
(IU/mg protein)
Injected
protein per
75 IU (mcg)
< 5%
~100
~750
< 70%
2,000–2,500
~33
13,645
Size Exclusion High
Performance Liquid
Chromatography
(SE- HPLC)
6.1
rec-hFSH* > 99%
*Follitropin alfa; Bassett et al. Reprod Biomed Online 2005
Esteves, 9
ANDROFERT, Referral Center for Male Reproduction

10. Quantity vs. Quality
which one come first?
• Oocyte/embryo quality?
• Endometrial receptivity?
Esteves, 10
ANDROFERT, Referral Center for Male Reproduction

11. Morphology-based embryo quality
and number of oocytes
Embryo quality score
Implantation rate (%)
A large oocyte
1,301 cycles
23
cohort was the
17
main factor that
increased the
3,8
4,5
chance of having
at least one good
1-6 oocytes
embryo
7-15 oocytes
27
p<0.001
4,8
>15 oocytes
Devreker et al Hum Reprod 1999
Esteves, 11
ANDROFERT, Referral Center for Male Reproduction

12. Aneuploidy and Oocyte Yield
Aneuploidy rate %
60
634 patients; 3,688 oocytes; PB biopsy
50
<35 years
40
35-40 years
>40 years
30
20
10
0
p<0.001
The higher the oocyte cohort, the higher the
number of EUPLOID oocytes in all age groups
1-5 oocytes
6-10 oocytes >10 oocytes
Haaf et al Fertil Steril 2009
Esteves, 12
ANDROFERT, Referral Center for Male Reproduction

13. 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
Esteves, 13
ANDROFERT, Referral Center for Male Reproduction

14. 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
Esteves, 14
ANDROFERT, Referral Center for Male Reproduction

15. What we have learned
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
Esteves, 15
ANDROFERT, Referral Center for Male Reproduction

16. How to get the best results
oocyte quality vs. quantity
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
Esteves, 16
ANDROFERT, Referral Center for Male Reproduction

17. More is good, but does it affect
implantation?
• Oocyte/embryo quality?
• Endometrial receptivity?
Esteves, 17
ANDROFERT, Referral Center for Male Reproduction

18. Effect of progesterone levels on
pregnancy in IVF – Do they matter?
Fresh
Frozen-thawed
Donor/recipient
P
ng/mL
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
OR: 1.18
(0.76 – 1.84)
OR: 0.64
OR: 1.03
(0.79 – 1.34)
OR: 0.83
(0.62 – 1.32)
(0.64 – 4.05)
OR: 0.62
(0.57 – 0.69)
OR: 1.13
(0.97 – 0.69)
-
OR: 0.67
OR: 1.03
OR: 0.51
(0.55 – 0.81)
(0.84 – 1.27)
(0.12 – 2.19)
1.2-1.4
1.5-1.75
1.9-3.0
(0.56 – 0.94)
(0.53 – 0.77)
OR: 1.61
P levels not related to oocyte and embryo
quality, nor with fertilization and cleavage rates
Venetis et al., Hum Reprod Update 2013
Esteves, 18
ANDROFERT, Referral Center for Male Reproduction

19. 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
Esteves, 19
ANDROFERT, Referral Center for Male Reproduction

20. No CYP17
LH
Esteves, 20
FSH
LH

21. hMG
Grondal et al. 2009:
r-FSH
P levels with rec-hFSH and hMG
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-fold
Lower steroids synthesis and P levels
 Higher potency of rec-hFSH inducing
more LH/hCG receptors
Esteves, 21
Grondal ML et al. Fertil Steril 2009; 91: 1820-1830.
Menon KM et al. Biol Reprod 2004; 70:861-866

22. 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.
Esteves, 22
ANDROFERT, Referral Center for Male Reproduction

23. Progesterone levels
and pregnancy
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
■ Fresh
■ FET
2.25
Esteves, 23
ANDROFERT, Referral Center for Male Reproduction

24. Do we need to measure P levels at hCG
day in stimulated cycles?
How often P4 rise:
Overall: 8.4%
Low-responder: 4.5%
High-responder: 19%
6 RCT, N=1866; Antagonist cycles
OPR not impaired in
high responders
with P elevation
Ongoing PR: OR = 0.55 (0.37–0.81)
Griesinger et al. Fertil Steril 2013
Esteves, 24
ANDROFERT, Referral Center for Male Reproduction

25. Effects of progesterone levels at hCG day
on pregnancy
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
Wickenheisser et al. Trends Endocrinol Metab. 2006; 17(2): 65-71;
Nguyen PT et al. J Theor Biol. 2013; 332: 52-64.
Esteves, 25
ANDROFERT, Referral Center for Male Reproduction

26. ANDROFERT
Number of oocytes and cumulative
live birth rate
Esteves, 26
+25.0%
Female Age ≤38
+18.8%
40,4%
ET #1 (fresh)
822
332/822
50.5%
48,0%
ET #2 (FET)
239
63/239
ET #3
(FET) 49
17/49
ANDROFERT, Referral Center for Male Reproduction

28. Cumulative live birth to improve
treatment outcome in ART
Pillar #1 – IVF facilities
Esteves, 28
ANDROFERT, Referral Center for Male Reproduction

29. Esteves & Bento. RBM Online 2013

30. Esteves & Bento. RBM Online 2013

31. Cumulative pregnancy to improve
treatment outcome in ART
Pillar #2 – Blastocyst Culture
Identify the embryos with
optimal development potential
Meta-analysis of eight RCT with
1,654 patients
LBR with Blastocyst vs. Cleavage-stage ET
35% x 28%; OR: 1.39; 95% CI: 1.10-1.76
Papanikolaou E et al. Hum Reprod 2008
Esteves, 31
ANDROFERT, Referral Center for Male Reproduction

32. Identification of Embryos with Optimal
Development Potential
Time-lapse Technology
Videomicrography + Computer Vision Software
(Eeva; Auxogyn)
Wong et al, 2010
Esteves, 32
ANDROFERT, Referral Center for Male Reproduction

33. Cumulative pregnancy to optimize
treatment outcome in ART
Pillar #3 – Vitrification
Vitrification vs. Slow-freezing
Ongoing PR: 35% x 27%;
OR: 1.82; 95% CI: 1.04-3.20
Meta-analysis of five RCT with
765 cycles
AbdelFahez et al . RBM Online 2010
Vitrification is simpler and faster
than Slow Freezing
Esteves, 33
ANDROFERT, Referral Center for Male Reproduction

34. Cumulative pregnancy rate as a
strategy to improve success in IVF
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
Esteves, 34
ANDROFERT, Referral Center for Male Reproduction

35. 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
Esteves, 35
ANDROFERT, Referral Center for Male Reproduction

36. 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
Esteves, 36
ANDROFERT, Referral Center for Male Reproduction

37. 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)
Esteves, 37
ANDROFERT, Referral Center for Male Reproduction

38. obrigado
Thank You