This presentation is about the women infertility and role of L-leucine in patients with poor ovarian reserve

1. Evaluating the effect of L-Leucine pre-treatment on
ovarian response and embryo quality in poor ovarian
response (POR) patients undergoing controlled ovarian
stimulation: A pilot observational study
Presented by
Vijay Rathod, PhD

2. Female Infertility
• Infertility occurs when:
– A woman is not able to get pregnant after
a year of trying, or
– 6 months if she is at the age of 35 years or
older.
• Infertility affects lives of at least 10% of
women of childbearing age.
• Female infertility is treatable condition
in the majority of cases.
2
Ref: https://www.shecares.com/pregnancy/fertility/female-infertility

3. Causes of Female Infertility
• Hormonal Imbalance
– Functioning of reproductive system
mainly governed by hormones
– Particularly estrogen and progesterone
• Damage or Blockage in the
Reproductive Tract
– Occurs due to damage or blockage of
cervix, fallopian tubes, or uterus
– Condition result in:
• Tubal infertility
• Scarred Uterus
3
Ref: https://www.shecares.com/pregnancy/fertility/female-infertility

4. Ovarian Response
• The quantity of oocytes obtained after ovarian stimulation
during IVF.
• This is carried out in order to obtain an adequate amount of
oocytes to guarantee favourable embryo prospects.
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Ref- https://www.institutobernabeu.com/en/ib/poor-ovarian-response-unit/

5. Ovarian reserve
• The total quantity of suitable oocytes available in a woman's
ovaries at any given time.
• A low ovarian reserve is the main cause of poor ovarian
response.
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Ref: -https://www.institutobernabeu.com/en/ib/poor-ovarian-response-unit/

6. Poor Ovarian Response
• It is a result of decreased quantity and quality of oocytes in
women of reproductive age group.
• Majority or women with POR need to undergo in
vitro fertilization (IVF) to achieve pregnancy.
• Nearly 10% of the women undergoing IVF will show poor
response to gonadotropin stimulation.
• POR may be associated with low pregnancy rates irrespective
of age and a high pregnancy loss.
• Estimated prevalence for POR :- 5-25%
• Prevalence increases with age
- >50% over 40 years
- 62.4% will have repeat poor response
6J irge PR. J Hum Reprod Sci. 2016 Apr-Jun; doi: 10.4103/0974-1208.183514.
Klinkert ER et al. J Assist Reprod Genet. 2004. doi:10.1023/b:jarg.0000027016.65749.ad

7. Features for diagnosis of POR
Bologna criteria
• Elevated follicle stimulating hormone (FSH)
• Maternal age (≥40 years)
• Previous POR (≤3 oocytes)
• An abnormal ovarian reserve test:
– Antral follicle count (AFC), 5-7 follicles or
– Anti-Mullerian Hormone (AMH) 0.5-1.1 ng/ml.
NICE (2013) criteria to predict risk of poor response:
• Total antral follicle count ≤4
• Anti-Müllerian Hormone ≤ 5.4 pmol/L (2.4 ng/ml)
• Follicle-Stimulating Hormone ≥ 8.9 IU/L
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Ref-J irge PR. J Hum Reprod Sci. 2016 Apr-Jun; doi: 10.4103/0974-1208.183514.

8. Tests ESHRE
Bologna 2010
ASRM 2012 NICE 2013
Age > 40 years
FSH 10-20IU/L ≥8.9 IU/L
AMH < 0.5-1.1 ng/ml 0.2-0.7 ng/ml ≤5.4 pmol/L (0.75
ng/ml)
AFC < 5-7 3-10 ≤4
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Contd..

9. Management of POR
1. Controlled ovarian stimulation for in vitro fertilization
– Widely used
– high doses of FSH (300–450 IU/day)
2. Agonists
– Widely used to prevent an endogenous LH surge.
– Long/Short agonist - to effect follicular development in poor responders.
3. Antagonists
– For preventing premature LH surge without prolonging the treatment duration.
4. Natural cycle in vitro fertilization
– an alternative to the high-dose regimens in POR to reduce the gonadotropin burden.
5. Pretreatment
– Pretreatment with oral contraceptive pills (OCPs), progesterone, or ethinyl estradiol to
improve follicular synchronization, prevent premature ovulation, and scheduling of cycles.
6. Adjuvant therapy
– improve the intrafollicular environment and follicular sensitivity to exogenous FSH
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Ref-J irge PR. J Hum Reprod Sci. 2016 Apr-Jun; doi: 10.4103/0974-1208.183514.

10. mTOR Signaling in
Female Reproduction
 Mammalian target of rapamycin
(mTOR) signalling integrates
extracellular and intracellular
signals to regulate
o protein translation,
o cell metabolism,
o Cell growth, proliferation, and survival.
 Beside, it also participates in various
process that occur in the ovary
including:
– ovarian reserve,
– follicle development,
– oocyte meiotic maturation, and
– ovarian ageing, and proliferation
10
Ref- Guo Z, Yu Q et al. Front Endocrinol (Lausanne). 2019 Oct 9. doi: 10.3389/fendo.2019.00692.

11. 11Ref- Telfer EE et al. Fertil Steril. 2013 May. doi: 10.1016/j.fertnstert.2013.03.043.

12. mTor Modulator
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Inhibitors Activators
Rapamycin1
Leucine5
All Rapamycin Analogs1
(Tacrolimus, everolimus, & temsirolimus etc.)
Metformin2
Resveratrol3
TORKinibs4
1. Kaeberlein M. Scientifica (Cairo). 2013. doi: 10.1155/2013/849186.
2. Amin S et al. Br J Clin Pharmacol. 2019 Jan. doi: 10.1111/bcp.13780.
3. Park D et al. Sci Rep. 2016 Feb 23 doi: 10.1038/srep21772.
4. Zaza G et al. Transplantation. 2018 Feb. doi: 10.1097/TP.0000000000001806.
5. Boultwood J et al. Adv Biol Regul. 2013 Jan. doi: 10.1016/j.jbior.2012.09.002.

13. Leucine- An Activator of mTor
 Leucine is an essential amino acid and a nutrient signal that
activates complex 1 of the mammalian target of rapamycin
(mTORC1).
Ref: - Ananieva EA et al.Adv Nutr. 2016 Jul 15. doi: 10.3945/an.115.011221.
Fig 1. Overview of leucine metabolism.
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14. Manufacturers in India
Manufactures Leucine formulation Content Indication
Nutri Synapzz
Therapeutis Pvt Ltd
M-Torr 800 mg Leucine,
Isoleucine,
And valine
Increase energy
and stamina
Nutri Synapzz
Therapeutis Pvt Ltd
M-Torr 400 mg Leucine Increase energy
and stamina
Influx Healthcare M-Torr 800, 400 mg Leucine Nutritional
supplement
Influx Healthcare M-Torr 400 mg Leucine Nutritional
supplement
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https://pharmeasy.in/online-medicine-order/m-torr-800mg-cap-10-s-194466
https://www.pulseplus.in/product/m-torr-capsule-pc-22362

15. Why this study matters
• Several animal studies have been conducted to identify the
role of:
– mTOR pathway in folliculogenesis, and
– Role of leucine in the regulation of mTOR pathway
• But no human studies have been conducted.
mTOR
Pathway
folliculogenesis
Effect of leucine
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16. Methodology
Study design Pilot observational longitudinal cohort study in
a tertiary care fertility clinic and reproductive
Medicine Institute
Study duration 4 months
Sample size 30 POR patients with one previous failed IVF
cycle.
Dosage All patients were supplemented with 800mg of
L-leucine (MtorrTM, NutriSynapz Therapeutix)
OD after meals for 3 months before
undergoing 2nd cycle of controlled ovarian
stimulation.
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17. Primary and secondary outcomes
• Changes in :-
– Antral follicle count,
– Anti-Mullerian hormone,
– Estradiol level,
– Average oocyte number,
– Total Metaphase 2(M2) oocytes, and
– Average number of day 3 cleavage Grade A Embryos.
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18. Key Findings
• After treatment (Mtorr 800 capsules OD for 3 months) vs before
treatment increased:-
– Mean Antral follicle count (8.2 vs 6.9; P = .01),
– Average number of day 3 cleavage grade A embryos (2.23 vs 1.4; P = .01),
– Average oocyte number (5.53 vs 4.53; P = .06),
– Mean Anti-Mullerian hormone level (1.8ng/ml vs 1.3), and
– Estradiol level (1473.4pg/ml vs 1308).
Ref:- 1 P-615 Pilot observational study evaluating the effect of L-Leucine pretreatment on ovarian response and embryo quality in Poor Ovarian Response (POR) patients undergoing controlled ovarian stimulation, Vohra A et al.
Milann Fertility Centre, Bangalore, India. Presented @European Society of Human Reproduction and Embryology (ESHRE2019).
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19. Contd..
• Total Metaphase 2 oocytes retrieved were observed to
increase by an average of 1 oocyte after 3 months of
treatment with L-leucine.
19
Ref:- 1 P-615 Pilot observational study evaluating the effect of L-Leucine pretreatment on ovarian response and embryo quality in Poor Ovarian Response (POR) patients undergoing controlled ovarian stimulation, Vohra A et al.
Milann Fertility Centre, Bangalore, India. Presented @European Society of Human Reproduction and Embryology (ESHRE2019).

20. Limitations
1) Observational study
2) Small sample size
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21. Takeaway
 Treatment with Mtorr 800 capsules showed an improvement in mean
AFC, AMH, estradiol levels, number of oocytes retrieved and number of
Grade A embryos in patients with POR.
 Significant Increase in total Grade A embryos improves probability of an
embryo transfer in a poor responder.
 For a poor responder, one extra oocyte or embryo could increase the
chance of pregnancy and possibly avoid donor egg program.
 Mtorr 800 cap could offer hope to POR patients where improvement in
ovarian response and embryo quality for better chances of pregnancy.
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22. References
1) Telfer, E. E., & Zelinski, M. B. (2013). Ovarian Follicle Culture: Advances
and Challenges for Human and Non-human Primates. Fertility and
Sterility, 99(6), 1523–1533.
2) Deepak Adhikari, Kui Liu. (2010). mTOR signaling in the control of
activation of primordial follicles. Cell Cycle 9:9, pages 1673-1674.
3) Ananieva, E. A., Powell, J. D et al. (2016). Leucine Metabolism in T Cell
Activation: mTOR Signaling and Beyond. Advances in Nutrition, 7(4),
798S–805S.
4) Fleming, R., Seifer, D. B., et al (2015). Assessing ovarian response: antral
follicle count versus anti-Müllerian hormone. Reproductive BioMedicine
Online 2015Volume 31, Issue 4, Pages 486–496
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23. Thank you
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