Aula ministrada pelo Dr. Sandro Esteves no 5th. Dubai International Obs-Gyne & Fertility Conference & eXHIBITION DIOFCE 2010, em 05 de novembro de 2010.

1. Improving Success by Tailoring
Ovarian Stimulation
- We are all individuals -

2. Lecture Outline

3. UN Census Estimates, 2008

7. Ovarian Stimulation
Pharmaceutical industry
One size fits all protocol for OS
suppress LH surge: GnRHa
ovarian stimulation with HMG/FSH
high doses of gonadotropin
high number oocytes
high number of embryos
Results not the same for all
poor response and OHSS
side effects
patient satisfaction neglected

8. Psychological burden 49%-26%
Prognosis 40%-23%
Cost of treatment 23%-0%
Relationship/divorce 15%-9%
Physical burden 7-6%
Up to 65% of couples dropout
from IVF without achieving
pregnancy before they
complete 3 cycles1-5
Oocyte retrieval 52%
Embryo transfer 29%
Injections 29%
Physical pain 20%
Blood tests 14%
1. Olivius K t al, Fertil Steril 2004;81:258; 2. Land JA et al, Fertil Steril 1997; 68:278; 3. Schroder AK, et al, RBM Online 2004; 5:600; 4.
Osmanangaoglu K et al, Hum Reprod 2002; 17:2655; 5. Rajkhowa M et al, Hum Reprod 2006; 21:358; 6. Brandes M et al, Hum Reprod 2009;
24:3127; 7. Hammarberg K et al, Hum Reprod 2001; 16:374.
Reasons1,5,6
IVF events women find stressful7
Pregnancy loss 94%
Unsuccessful cycle 87%
Waiting after ET 81%
Waiting to find out how many
eggs fertilized
68%
Result of pregnancy scan 47%
Patient Satisfaction
Why should I care?

9. Ovarian Stimulation
One size fits all?
Patient is the main
variable of OS response
 Demographics and
anthropometrics (Age,
BMI, Race)
 Genetics profile
 Cause of Infertility
 Years of Infertility
 Health status
 Nutritional status

10. How to define the right individual
treatment for the right patient:
● Prevent poor response and
OHSS (reduce cancellation)
● Reduce side effects
● Increase pregnancy rates
● Reduce physical, psychological
and financial burden
Understanding the Problem
What we really want to know is...
Esteves, 10

11. Lecture Outline
Gonadotropins:
better now

12. Age
Biomarkers
● Hormonal Biomarkers, FSH, Inhibin-B, AMH
● Functional Biomarkers: Antral Follicle Count (AFC)
● Genetic Biomarkers: Single Nucleotide Polymorphisms for
FSH-R/LH/LH-R/E2-R/AMH-R
Markers of Ovarian Response
Can we predict ovarian response?
Esteves, 12

13. 1. Akande et al. Hum Reprod 2002;17:2003–2008
(n = 1019)
20–24 25–29 30–34 35–39 40–44 45–49
5
0
10
15
20Livebirths(%)
Age (years)
6–8.9
3–5.9
<3
FSH IU/L
≥12
9–11.9
Age and FSH
chronological vs biological in IVF
MariaHana
Esteves, 13

14. La Marca, et al. Hum Reprod 2009.
AMH levels are
correlated with
the number of
follicles at
gonadotropin
independent
stage
Markers of Ovarian Response
Biomarkers and follicular development
Esteves, 14

15. AMH: a cut-off 1.26 ng/ml was able to predict
poor response (<4 oocytes) with 97% sensitivity
Gnoth, et al. Hum Reprod 2008.
Retrospective analysis, 316
patients (1st IVF cycle) in
GnRH-a long protocol
Variables: age, basal FSH, AMH,
Inhibin-B
Endpoint: number of oocytes
Cut-off of poor response: 4 oocytes
Markers of Ovarian Response
anti-Mullerian hormone (AMH)
Esteves, 15

16. Verhagenet al. 2008; Broer et al., 2010
Markers of Ovarian Response
Prediction of response by AMH
AMH category (ng/mL) 0.14 to <0.7 (N=74) 0.7 to <2.1 (N=128) >2.1 (N=148)
Agonist protocol + rFSH 375 225 150
Oocytes (n) 5 (3-7) 10 (7-15) 14 (10-19)
Severe OHSS 0 (0%) 3 (2%) 20 (13.9%)
Cancellation 19 (25.7%) 3 (2.3%) 4 (2.7%)
CPR per transfer 11.1% 34.6% 40.1%
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.
Esteves, 16

17. Markers of Ovarian Response
Antral Follicle Count (AFC)
No. of antral
follicles
< 3 4-10 > 10
No. of cycles 16 76 57
Mean age (years) 36.8 2.9 36.3 4.0 32.8 3.8
Day 3 FSH (IU/l) 12.7 8.5 7.1 4.1 5.6 1.7
Cx rate 68.8% 5.3% 0%
Peak E2 (pg/ml) 432 157 1.001 627
1.912
1.355
Mean No. of eggs 2.0 0.9 6.3 4.4 14.1 8.5
OG pregnancy
rate
0% 13.2% 26.3%
Chang, et al. Fertil Steril. 1998;69:505.
Hansen KR, et al. Fertil Steril
2003;80:577–83
Number of antral follicles
Meannumberofoocytesretreived
r=0.64
p<0.001
0 5 10 15 20 25
25
20
15
10
5
0
Esteves, 17

18. Markers of Ovarian Response
Antral Follicle Count (AFC)
Broekmans et al., Fertil Steril, 2009
Clinical considerations
● Cycle day 2-4
● Count all AF 2-10mm
Technical considerations
● Real-time 2 dimension
image adequate
● Transvaginal probe 7Mhz
minimum
Esteves, 18

19. Broer et al. , 2010
AMH = AFC >Inhibin B >FSH >Age
Markers of Ovarian Response
Prediction of response
Esteves, 19

20. Lecture Outline

21. Gonadotropins: better today
Urinary-derived products

22. Culture media
HarvestBioreactor
Production
Cell attachment and
proliferation
r-hFSH production and
secretion
Collection of cell
culture supernatant
medium containing
r-hFSH
In-process QC
Purification
Concentration of
supernatant
Chromatographic
purification
steps
Ultrasterile filtration
Characterization
and full QC of
bulk r-hFSH
Esteves, 22
Gonadotropins: better today
Recombinants

23. Gonadotropins: better today
From urinaries to recombinants
Bassett et al. Reprod Biomed Online 2005;10:169–177
Purity
(FSH
content)
Mean specific
FSH activity
(IU/mg protein)
Injected
protein
per 75 IU
(mcg)
hMG < 5% ~100 ~750*
hMG-HP < 70% 2000–2500 ~33*
r-hFSH
Follitropin beta – 7000–10,000 8.1*
Follitropin alfa > 99% 13,645 6.1
Esteves, 23

24. 1. Bassett et al. Reprod Biomed Online 2005;10:169–177
2. Driebergen et al. Curr Med Res Opin 2003;19:41–46
Conventional
Bioassay
High
variability
(~20%)
in vivo (rat)
Novel analitycal
method
Physiochemical
technique
Minimal batch-to-
batch variability
(1.6%)1,2
Gonadotropins: an overview
Product Quality: Filled by Mass (FbM)
Esteves, 24

25. Concept of Dose Precision
Clinical implications
Batch variability
+20%, -25%
225
270
170
IU
Bioassay
Urinary and Follitropin beta
16.5 mcg
(225 IU)
Filled by Mass
Folitropin alfa (Gonal-f FbM)
Batch variability
 2%
Risk of OHSS
Poor response

26. Esteves, 26
18.7 20.3
53.4*
% Cycles with “Step-down”
during ovarian stimulation
HMG HP-HMG rec-hFSH (fbm)
*P<0.01
TotalDoseperLiveBirth(IU)* 0
3.000
7.000
10.000
21.6%
r-hFSH HP-hMG
6,324*
7,739
hMG
9,690
52.2%
* Mean total dose per cycle/Live birth rate
(≤35 years)

27. LH surge prevention
GnRH antagonists
pyro (Glu) – His – Trp – Ser – Tyr – Gly – Leu – Arg – Pro – Gly – NH2
Activation of the
GnRH receptor
Regulation of
receptor affinity
Regulation of receptor
biological activity
Antagonistic
effect
1 32

28. Agonist administration
Gonadotropin administration
Long GnRH
agonist protocol
Antagonist
administration
Gonadotropin administration
Single or multiple
dose GnRH
antagonist protocol
Flare up
effect
Pituitary
suppression
Longer
treatment
Can exclude
early
pregnancy
Can be integrated
in spontaneous
and OI cycles
Pre-treatment cycle Treatment cycle
No hormonal
withdrawal
No flare
effect with
possible cyst
formation
Less gona-
dotropins
Prevent OHSS
by GnRH-a
LH surge prevention
GnRH antagonists vs agonists

29. Kolibianakis et al (2006)2
N studies 22
Included non peer-reviewed data No
Included IUI cycles No
N patients 3176
Odds ratio 0.86 (0.72-1.02; p=.08)*
Duration of stimulation -1.54 days (OR: -2.42; -0.66; p=.0006)
Oocytes retrieved -1.19 (OR: -1.82; -0.56)
Risk of severe OHSS OR=0.61 (0.42; 0.89; p=.01)*
GnRH antagonists vs agonists
Meta-analysis
*For every 59 women treated with a GnRH agonist vs GnRH
antagonist, one additional case of severe OHSS will occur.
Esteves, 29

30. Lecture Outline

31. AMH category (ng/mL) >2.1
GnRH analogue + r-hFSH 150UI Agonist Antagonist
Oocytes (n) 14 (10-19) 10 (8.5-13.5)
Severe OHSS 20 (13.9%) 0 (0%)*
Cancellation 4 (2.7%) 1 (2.9%)
CPR per transfer 40.1% 63.6%*
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
Individualized Treatment with AMH
AMH + antagonists in hyper-responders
Esteves, 31

32. 31.3% 31.1%
35.3%
50.0%
20.0%
0%
10%
20%
30%
40%
50%
60%
75 IU 112.5 IU 150 IU 187.5 IU 225 IU
Clinical pregnancy rates/cycle
started
Olivennes F, et al. The CONSORT study. Reprod Biomed Online. 2009;18:195–204.
Individualized dosing in
increments of 37.5 IU of
Gonal-f possible by FbM
technology
Use of algorithm of
patients characteristics
● basal FSH
● body mass index (BMI)
● age
● antral follicle count
Age (28-32)
Oocytes retrieved (8-12)
CONSORT = CONsistency in r-hFSH
Starting dOses for Individualized
tReatmenT
Esteves, 32

33. 1. Alviggi et al. Reprod Biomed Online 2006;12:221–233; 2. Tarlatzis et al. Hum Reprod 2006;21:90–94
3. Esteves et al. Reprod Biol Endocrinol 2009;7:111; 4. Marrs et al. Reprod Biomed Online 2004;8:175–182
5. Mochtar MH, Cochrane Database, 2007; 6. De Placido et al. Clin Endocrinol (Oxf) 2004;60:637–643
7. Alviggi, et al. RBMOnline 2009.
LH supplementation in ART
What do we know today
 The majority of patients do not need LH
supplementation as endogenous LH levels are
sufficient1–3
 15-20% of women have less sensitive ovaries
Older patients (> 35 years)4
Low responders5
Deeply suppressed endogenous LH6
Hypo-responders7
FSH and AFC considered adequate
Genetic characteristics
Single nucleotide polymorphisms of FSH-R and LH-R
Esteves, 33

34. Mochtar MH, Cochrane Database, 2007
No difference in basal LH levels.
Less bioactive LH/LH receptor polymorphism ?
LH supplementation in ART
Cochrane review 2007: hypo-responders
r-hFSH vs r-hLH + r-hFSH (Ongoing PR)

35. Tailoring Ovarian Stimulation
Treatment individualization strategies
• Antagonist + r-FSH FbM 112.5-150 UI
• Normal oocyte yield
• Very low cancellation/OHSS
• Adequate LBR
High
Responders
AFC >10
AMH >2.1
• Antagonist or Agonist + r-hFSH 187.5-262.5 UI
• Low cancellation & OHSS
• Adequate LBR
Normal
Responders
AFC 4-10
AMH 0.7-2.1
• Antagonist + r-hFSH (+r-hLH) 300-375 UI
• Short stimulation
Moderate cancellation
Low LBR
Poor
Responders
AFC <4
AMH <0.7

36. Thank you...