Lecture delivered at the 25th Annual Meeting of the Middle East Fertility Society, Beirut, Lebanon, November 2nd, 2018.

1. Sandro C. Esteves
ANDROFERT & University of Campinas (UNICAMP)
Campinas, BRAZIL
ON INDIVIDUALIZATION OF
OVARIAN STIMULATION:
The arguments in favor
25th Annual Meeting – Middle East Fertility Society – Beirut, Lebanon

2. ESTEVES, 2
Sandro Esteves, MD., PhD.
• Medical and Scientific Director, ANDROFERT, Campinas, BRAZIL
• Collaborating Professor, Department of Surgery, University of Campinas
(UNICAMP), BRAZIL
• Research Collaborator, American Center for Reproductive Medicine, Cleveland
Clinic, USA
• Research Collaborator, Genetic Unit, Universidad Autónoma de Madrid, SPAIN
• Honorary Professor of Reproductive Endocrinology, Faculty of Health, Aarhus
University, DENMARK
Declare receipt of lecture fees from Merck, Besins, Lilly, and Gedeon-Richter
Disclosure

3. Modified from Smith et al. JAMA 2015
156,947 UK women
(257,398 IVF cycles;
cumulative LBR using
fresh and frozen ET)
With increased women’s age in ART programs,
we should maximize reproductive outcomes and shorten TTLB
Esteves, 3

4. Only female age and number of oocytes can predict LBR
Modified from McLernon et al. BMJ 2016
Modified from Sunkara et al. Hum Reprod 2011
Modified from Drakopoulos et al. Hum Reprod 2016
CumulativeLiveBirth(%)
Esteves, 4

5. Modified from 8. De Geyter et al. Swiss Med Wkly 2015
Female age is an independent predictor of live birth
Esteves, 5

6. Esteves et al., ESHRE 2018; O-007;
Esteves et al. PanMinerva Medica 2018
Probability of a
Blastocyst
Being Euploid
Declines with
Age
Less than 50% overall
in women older than 35
Euploidy probability vs Female age
Esteves, 6

7. Negative effect of female age on blastocyst euploid
probability is progressive
% decrease in blastocyst euploidy probability from year (t) to year (t+1) defined
as the ratio p(t+1)/p(t) x 100
Geometric mean of the yearly variation: 13.6%
Esteves, 7
Esteves et al. ESHRE 2018 O-007: Estimation of age-dependent decrease in blastocyst euploidy in IVF/ICSI cycles

8. IVF is process-based, the first step being consulting & diagnosis
Esteves, 8

9. Esteves, 9
Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number
POSEIDON GROUP
Poseidon Group. Fertil Steril 2016

10. Esteves,
10
Low prognosis groups
Young Older
Adequate
ovarian
reserve
Poor
ovarian
reserve
Courtesy of Chloe Xilinas, EXCEMED
Poseidon Group. Fertil Steril 2016; 10. Humaidan et al. F1000Research 2016
Hypo-
responders &
Suboptimal
responders
Expected POR
<35
2a
2b

11. Esteves, 11
Group 1
Young & Suboptimal/Low
Oocyte Number
Group 2
Old & Suboptimal/Low
Oocyte Number
Group 3
Young & Expected Low
Oocyte Number
Group 4
Old & Expected Low
Oocyte Number
High
embryo
aneuploidy
risk
Low
embryo
aneuploidy
risk
Few embryos generated
Reduced Cumulative Live Birth Rate
Poseidon
Patients

12. Esteves,
12
Courtesy of Chloe Xilinas, EXCEMED
Prevalence of low prognosis patients according to POSEIDON criteria
5% 30%
10% 55%
47%
Poseidon
1-4
53%
Non Poseidon
N=432 – YEAR 2017
Source: ANDROFERT

13. Introduced an Intermediate Marker of Success in ART:
the Ability to Retrieve the Number of Oocytes Needed to Obtain
at Least One Euploid Blastocyst for Transfer in Each Patient
Poseidon Group. Fertil Steril 2016; Humaidan et al. F1000Research 2016
What is new in POSEIDON?
Introduced the Concept of ‘Low Prognosis’ in ART
Combined Oocyte Quality and Quantity for Identification
and Stratification of the ’Low Prognosis’ Patient
Included ’Hypo-responders’ as a Distinct Category
of ’Low Prognosis’ Patients
Introduced an Intermediate Marker of Success in ART:
the Ability to Retrieve the Number of Oocytes Needed to Obtain
at Least One Euploid Blastocyst for Transfer in Each Patient
Esteves, 13

14. Courtesy of Ubaldi & Rienzi (GENERA; Jan 2012-Dez 2013)
Source: ANDROFERT; Jan 2015-Sept 2016 (PGT-A by NGS)
Live birth (%)
Availability of euploid embryos maximizes IVF efficiency by
offsetting the negative effect of age on implantation and
pregnancy
Esteves, 14

15. http://www.members.groupposeidon.com/Calculator
Estimation can be done by means of a mathematical function
taking into account relevant predictive factors
Input variables
• Maturation rate
• 2PN Fertilization rate
• Cleavage or Blastulation rate
• Euploidy rate per age group
Adjusted according to maternal
and paternal age, sperm source,
sperm and oocyte status,
and type of embryo transfer
(fresh; FET)
Output variable
Y (N oocytes)
Function
Y = f(X)
Esteves, 15

16. There are two ways to do that…
the HARD WAY the EASY WAYand
Esteves, 16

17. http://www.members.groupposeidon.com/Calculator
Esteves, 17

18. Esteves, 18 Poseidon Group. Fertil Steril 2016; Humaidan et al. F1000Research 2016; Haahr et al. Reprod Biol Endocrinol 2018
POSEIDON Patient stratification system
(Ovarian biomarkers, Age, Number of oocytes if previous cycle)
Ovarian
Markers
Abnormal
Adequate
Age
G3 G4
G1 G2Suboptimal/
low oocyte
number
previous cycle Non POSEIDON SUB/LOW
YES
NO

19. Esteves, 19
Patient-oriented strategies are chosen with the mindset to
achieve the POSEIDON marker of success
individualized oocyte number to obtain at least one euploid embryo
for transfer
GnRH analogue regimen
Gonadotropin dose and drug type
Trigger strategy
Adjuvant therapy
Combined strategies (AccuVit; Duostim, etc.)
Personalized use of laboratory technology

20. Esteves, 20
Agonist or Antagonist rFSH alone or
rFSH + rLH (2:1 ratio) hCG or GnRH-a trigger
Agonist or Antagonist rFSH +
rLH (2:1 ratio) hCG or GnRH-a trigger
GnRH Antagonist + Low dose rFSH (100-175 IU)
+ GnRH-a trigger (<35yo)
GnRH Antagonist + rFSH + rLH (150:75 IU)
+ GnRH-a trigger (≥35yo)
Poseidon
G1 Poseidon
G2 Poseidon
G3 Poseidon
G4
Non
Poseidon
patients
Andersen et al. (eds.) Research Topic Frontiers in Endocrinology. In preparation
Gonadotropin starting dose and regimen can be determined in all patient
categories by Poseidon-based stratification

21. POSEIDON GROUPS 1 AND 2
Adequate pre-stimulation ovarian parameters but unexpected poor or suboptimal
oocyte number
Courtesy of Chloe Xilinas, EXCEMED
Esteves, 21
Alviggi, Conforti, Esteves et al. , Front. Endocrinol 2018

22. POSEIDON GROUPS 1 AND 2
Adequate pre-stimulation ovarian parameters but unexpected poor or suboptimal
oocyte number
Esteves, 22
Alviggi, Conforti, Esteves et al. , Front. Endocrinol 2018
Follicle to Oocyte Index (FOI):
Oocyte number/AFC

23. iCOS Treatment:
• GnRH antagonist (E2, noresthisterone, OCP priming)
• DuoStim?
• Increase gonadotropin dose (rFSH) up to 300 IU/d
• LH supplementation
iCOS Treatment:
• GnRH antagonist (E2, noresthisterone, OCP priming)
• Increase gonadotropin dose (rFSH) up to 225 IU/d
• LH supplementation
Management of Poseidon Groups 1 and 2
Adequate AFC and/or AMH 1.2 ng/ml;
Previous cycle with poor/suboptimal oocyte number
Group 1, young (AGE <35) Group 2, old (AGE ³35)
Adequate reserve - good quality - Hyporesponse Adequate reserve - poor quality - Hyporesponse
Reason for hypo-response:
• Low gonadotropin dose
• Asynchronous development
(Genetic polymorphism of FSH-R; LH-R; V-LH-β)
• Trigger/oocyte collection issues
Embryo Transfer strategy:
• R-hCG trigger/Dual trigger
• Fresh transfer if no risk OHSS
• Elective segmentation and FET
Measure of success:
In average, a total of 4-5 oocytes are needed
to obtain one euploid embryo
Reason for hypo-response:
• Low gonadotropin dose
• Asynchronous development
(Genetic polymorphism of FSH-R; LH-R; V-LH-β)
• Trigger/oocyte collection issues
Embryo Transfer strategy:
• R-hCG trigger/Dual trigger
• Fresh transfer if no risk OHSS
• Oocyte/embryo accumulation, PGT-A? and FET
Measure of success:
In average, a total of 12 or more oocytes are needed
to obtain one euploid embryo
Esteves, 23

24. iCOS Treatment:
• GnRH antagonist (E2, noresthisterone, OCP priming)
• DuoStim?
• Increase gonadotropin dose (rFSH) up to 300 IU/d
• LH supplementation
iCOS Treatment:
• GnRH antagonist (E2, noresthisterone, OCP priming)
• Increase gonadotropin dose (rFSH) up to 225 IU/d
• LH supplementation
Management of Poseidon Groups 1 and 2
Adequate AFC and/or AMH 1.2 ng/ml;
Previous cycle with poor/suboptimal oocyte number
Group 1, young (AGE <35) Group 2, old (AGE ³35)
Adequate reserve - good quality - Hyporesponse Adequate reserve - poor quality - Hyporesponse
Reason for hypo-response:
• Low gonadotropin dose
• Asynchronous development
(Genetic polymorphism of FSH-R; LH-R; V-LH-β)
• Trigger/oocyte collection issues
Embryo Transfer strategy:
• R-hCG trigger/Dual trigger
• Fresh transfer if no risk OHSS
• Elective segmentation and FET
Measure of success:
In average, a total of 4-5 oocytes are needed
to obtain one euploid embryo
Reason for hypo-response:
• Low gonadotropin dose
• Asynchronous development
(Genetic polymorphism of FSH-R; LH-R; V-LH-β)
• Trigger/oocyte collection issues
Embryo Transfer strategy:
• R-hCG trigger/Dual trigger
• Fresh transfer if no risk OHSS
• Oocyte/embryo accumulation, PGT-A? and FET
Measure of success:
In average, a total of 12 or more oocytes are needed
to obtain one euploid embryo
Esteves, 24
PHARMACOLOGICAL INTERVENTION

25. Esteves, 25
Modified from Lehert P et al. Reprod Biol Endocrinol 2010
Oocyte yield per gonadotropin type
recFSH > uFSH, HMG and HP-HMG
1.5 oocytes (GnRH antagonist protocol)(18)
2.1 oocytes (16 RCT; different protocols)(17)
3.1 oocytes (GnRH antagonist)(19)
2.8 oocytes (GnRH agonist protocol)(20)
1.8 oocytes (GnRH agonist protocol)(21)
Lehert P et al. Reprod Biol Endocrinol 2010; Devroey et al. Fertil Steril 2012; Bosch et al. Hum Reprod 2008;
Hompes et al. Fertil Steril 2008; Andersen et al. Hum Reprod 2006

26. Recombinant
Urinary
Oocyte number in IVF patients with FSH
receptor N680S polymorphism affected by
type of gonadotropin administered
Esteves, 26

27. Esteves, 27 Esteves, Yarali, Ubaldi et al. Validation of ART Calculator Study Group, Unpublished data
Increasing oocytes yield has no detrimental effects on
embryo ploidy
Response Number Euploid Blastocysts
Distribution Binomial
Estimation Method Logistic Regression
Validation Method Validation Column
Probability Model Link Logit
Generalized Regression for number Euploid Blastocysts Model Launch
Lasso [x] Adaptive
Term Estimate Std Error
Wald
ChiSquare
Prob >
ChiSquare
Lower
95%
Upper
95%
Intercept 6.2769104 0.6256681 100.64771 <0.0001* 5.0506235 7.5031972
Age Female -0.182507 0.152275 143.64894 <0.0001* -0.212352 -0.152662
Number
Blastocysts
0.0302516 0.0189943 2.536584 0.1112 -0.006977 0.0674797
Parameter Estimates for Original Predictors
3,108 Trophectoderm Biopsies
1,109 patients
Euploidy probability vs. number of blastocysts by age group

28. Esteves, 28
Higher ovarian response than that achieved with mild/natural ovarian
stimulation does not increase risk of embryo aneuploidy
Term Estimate Std Error
Wald
ChiSquare
Prob >
ChiSquare
Lower
95%
Upper
95%
Intercept 3.8117137 1.5331832 6.1809102 0.0129* 0.8067298 6.8166876
Age Female -0.22129 0.019748 125.56789 <0.001* -0.259996 -0.182585
typeOSGrou
ped[Convent
ional-Other]
0.065727 0.33909 0.0375714 0.8463 -0.598877 0.7303311
Response Number Euploid Blastocysts
Distribution Binomial
Estimation Method Adaptive Lasso
Validation Method Validation Column
Probability Model Link Logit
Adaptive Lasso with Validation Column Model Summary
Parameter Estimates for Original Predictors
1,632 Trophectoderm Biopsies by NGS
631 patients
Euploidy Probability vs Female Age, by OS Type
Esteves, Yarali, Ubaldi et al. Validation of ART Calculator Study Group, Unpublished data

29. 1)Patients with sufficient prestimulation
ovarian reserve parameters that have an
unexpected hyporesponse to FSH
monotherapy
r-hLH can be started either during the midfollicular
phase to rescue the ongoing cycle or on stimulation day
1 in a subsequent cycle
2) Women 36–39 years
r-hLH should be started on stimulation day 1
ESTEVES
, 29
Esteves, 29

30. ESTEVES, 30
Unpublished data; Source: ANDROFERT
Current Practice – Flexibility of iCOS
Rec-hFSH
Starting Dose Distribution (%)
% cycles with
Dose Adaptation after Sd5
53.4%

31. ESTEVES, 31
Current Practice – Flexibility of iCOS
% cycles
by Trigger Method
% cycles
with LH Activity Supplementation
12%
Dual trigger
43%
GnRH analog
45%
hCG
57%
Rec-LHc
43%
No-LH
Unpublished data; Source: ANDROFERT

32. Esteves, 32 Haahr et al. Reprod Biol Endocrinol 2018
Management of Poseidon poor prognosis patients
<AFC <5 and/or AMH <1.2 ng/ml
Group 3, young (AGE <35) Group 4, old (AGE >35)
Poor reserve - good quality Poor reserve - poor quality
Reason for poor response:
• Poor ovarian reserve
• Asynchronous development
(Genetic polymorphism of FSH-R; LH-R; V-LH-β)
iCOS Treatment:
• Long GnRHa protocol
• GnRH antagonist (E2, OCP)
• DuoStim ?
• Stimulation with 300 IU/d rFSH
• Androgens ?
Embryo Transfer strategy:
• Fresh transfer
• Oocyte/embryo accumulation and FET
Measure of success:
In average, a total of 4-5 oocytes are needed
to obtain one euploid embryo
Reason for poor response:
• Poor ovarian reserve
• Asynchronous development
• High Aneuploidy rate
(Genetic polymorphism of FSH-R; LH-R; V-LH-β)
iCOS Treatment:
• Long GnRHa protocol
• GnRH antagonist (E2, OCP)
• DuoStim
• Stimulation with 300 IU/d rFSH
• Androgens ?
Embryo Transfer strategy:
• Fresh transfer
• Oocyte/embryo accumulation, PGS?
and FET (Oocyte donation)
Measure of success:
In average, a total of 12 oocytes are needed
to obtain one euploid embryo

33. High FSH Dose
Author N Daily FSH dosage
N oocytes
(C)
N oocytes
(S)
Pregnancy
Cedrin durnerin 2000 96 POR 450 vs step-
down
6.4 6.3 NS (PR)
Klinkert 2005 52 POR 150 vs 300 3 3 NS (PR)
Berkkanoglu 2010 119 POR 300 vs 450 5.2 6.3 NS (PR)
Lefebvre 2015 356 POR(B) 450 vs 600 5 5 NS (PR)
Yousseff 2017 394 POR(B)150 vs 450 3.3 5 NS (PR)
Optimist 2016 501 POR 150 vs 450 6.5 7.6 NS
(PR/CPR)
Esteves, 33

34. ADJUVANTS (GH, DHEA, Testosterone)
Pregnancy
Outcome
RCT
showing benefit
RCT
showing no benefit
DHEA OPR Moawad & Shaeer (2012)
Xu et al. (2014)
Wiser et al (2010); Artini et al. (2012)
Kara et al. (2014); Yeung et al. (2014)
Testosterone CPR;
LBR
Kim et al. (2011) Massin et al. (2006);
Fabregues et al. (2009)
Bosdou et al. (2016)
GH CPR;
LBR
None Kucuk et al. (2008); Efteknar et al (2013)
Bassiouny et al. (2016)
Mixed results concerning duration of stimulation, No. oocytes retrieved, embryo
quality, cancellation rates
Esteves, 34

35. q No differences in oocyte quantity between groups
q Post-hoc analysis:
q Lower pregnancy loss with r-hFSH+r-LH than r-FSH
q Higher LBR with r-hFSH+r-LH than r-FSH in moderate/ severe POR
>900 patients (Bologna POR)
i. fixed-dose r-hFSH plus r-hLH
in a 2:1 ratio
ii. r-hFSH monotherapy
*Post-hoc AnalysisEsteves, 35

36. Current Practice - DUOSTIM
Esteves, 36
rFSH or rFSH+LH rFSH or rFSH+LH
Modified from Ubaldi et al. Fertil Steril 2016

37. POSEIDON–based
Stratification
FSH Starting Dose
Gonadotropin Dose
Adaptation
Flexible OS
(eg. LH, Duostim)
Maximize oocyte yield
to achieve estimated
N oocytes for at least
1 euploid embryo
Increased CLBR &
Reduced Time to Live
Birth
iART
Esteves, 37

38. ESTEVES, 38
www.groupposeidon.com
http://www.members.groupposeidon.com/Calculator

39. CLÍNICA DE ANDROLOGIA E LABORATÓRIO DE REPRODUÇÃO HUMANA
CENTRO DE REFERÊNCIA PARA REPRODUÇÃO MASCULINA
Dr. Sandro C. Esteves
Dr. Marcelo Scandiucci
Dr. José Eduardo Orosz
Dr. Renan Andreollo
Fabiola Bento
Cristiane Medina
Sidney Verza Jr.
Camila Pompeu
Luciana Oliveira
Vanessa Moreno
Ellen Silva
Roseane Oliveira
Thais Paiva
Sarah Queiroz
Katia Pereira
Sandra Souza
Leila Simplicio
Shirley Machado
Jonathan Santos
Dr. Silval Zabaglia
Dra. Fabiana Nakano
Dr. Julio Voget
Dr. Ricardo Miyaoka
Dr. Ricardo Barini
Dr. Wail Margeotto
Dra. Cristiane Moreira
Dr. Arnaldo Gomes
Marisa Russo
Ivanete Santos
Sandra Santana
Ana Paula Barbosa
Ana Pastorelli
THANK YOU
CHN/NONF/0818/0220