Optimize oocyte yield to maximize live birth in ART
•Download as PPTX, PDF•
2 likes•1,175 views
This document discusses strategies for optimizing ovarian response in ART to maximize live birth rates. It introduces the POSEIDON criteria for stratifying "low prognosis" ART patients based on age, ovarian reserve markers, and number of oocytes retrieved. The target is to retrieve over 15 oocytes to maximize cumulative live birth rates. Personalized gonadotropin protocols and adjuvant therapies can be used to optimize response based on POSEIDON stratification. This includes starting dose, supplementation with LH, and dual stimulation if needed to obtain the estimated number of oocytes for at least one euploid embryo transfer.
Recommended
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Optimize oocyte yield to maximize live birth in ART
Similar to Optimize oocyte yield to maximize live birth in ART (20)
More from Sandro Esteves
More from Sandro Esteves (20)
Recently uploaded
Recently uploaded (20)
Optimize oocyte yield to maximize live birth in ART
- 1. Sandro C. Esteves ANDROFERT & University of Campinas (UNICAMP), Campinas, Brazil Optimize oocyte yield to maximize live birth in ART
- 2. 2 Modified from 1. 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
- 3. 3 Quality Dimensions 1. Effectiveness (Technical aspects to deliver the best outcome) 2. Safety (risks, adverse effects, lab quality, etc.) 3. Patient centeredness (patient values and preferences) Success in ART The bottom line • Evaluate properly • Give a fair estimate of outcome • Develop a time-limited treatment plan 2. Dancet et al. Hum Reprod 2011; 3. Mainz. Int J Qual Health Care 2003
- 4. 4 AMH and AFC predict ovarian response but not LBR AMH~AFC>FSH>Age Predictors of Poor Response Predictors of Excessive Response Accuracy for Non-Pregnancy Prediction ~ 50-55% Modified from 4. Broer et al. Fertil Steril 2009 Modified from 4. Broer et al. Fertil Steril 2009Modified from 5. Broer et al. Hum Reprod Update 2011 Accuracy ~0.82 Accuracy ~0.78
- 5. 5 Only female age and number of oocytes can predict LBR Modified from 6. McLernon et al. BMJ 2016 Modified from 7. Sunkara et al. Hum Reprod 2011 Modified from 8. De Geyter et al. Swiss Med Wkly 2015
- 6. 6 Patient-Oriented Strategies Encompassing IndividualizeD Oocyte Number POSEIDON GROUP 9. Poseidon Group. Fertil Steril 2016
- 7. 7 Low prognosis groups Young Older Adequate ovarian reserve Poor ovarian reserve Courtesy of Chloe Xilinas, EXCEMED 9. Poseidon Group. Fertil Steril 2016; 10. Humaidan et al. F1000Research 2016
- 8. 8 Modified from 11. Drakopoulos et al. Hum Reprod 2016 Low Prognosis Owing to Decreased Number of Oocytes and thus lower CLBR Poseidon Patients Age-adjusted CLBR strongly influenced by oocyte number * Age adjusted (OR: 0.9; 95% Cl: 0.9-1.01) 21.7% 39.7% 50.5% 61.5%p=0.002 p=0.02 p=0.01
- 9. 9 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
- 10. 10 12. Esteves et al., Panminerva medica 2018 The older the women the lower the probability of euploid embryos, thus increasing the risk of NO transferable embryos Euploidy probability vs Female age Cycles with no transferable embryos Courtesy of Chloe Xilinas, EXCEMED Courtesy of Ubaldi & Rienzi. Genera Jan 2012 – Dec 2013
- 11. 11 Esteves et al., ESHRE 2018; O-007; 12. Esteves et al. Panminerva Med 2019 Decline in blastocyst euploidy probability increases progressively with female age Analysis of 1,220 trophectoderm biopsies from 436 patients undergoing ICSI and PGT-A with NGS 1.2 1.9 2.6 3.4 4.4 5.5 6.7 8.2 9.8 11.6 13.6 15.7 17.9 20.2 22.4 24.5 26.6
- 12. 12. Esteves et al. Panminerva Medica, 2019 To increase LBR/CLBR we need to maximize the number of oocytes % women with at least one euploid blastocyst as a function of age and embryo cohort size Embryo cohort size: P<0.001
- 13. 13 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
- 14. 14 The target is > 15 oocytes for maximizing CLBR Courtesy of Chloe Xilinas, EXCEMED Modified from 11. Drakopoulos et al. Hum Reprod 2016
- 15. 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 15 9. Poseidon Group. Fertil Steril 2016; 10. 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
- 16. 16 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 relevant factors affecting fertilization rates and embryonic parameters (eg., type of sperm, etc.) Output variable Y (N oocytes) Function Y = f(X)
- 17. 17 There are two ways to do that… the HARD WAY the EASY WAYand
- 18. 18
- 19. 13. Esteves et al. Front Endocrinol 201919 Development of ART Calculator Clinical & embryonic data of infertile couples subjected to IVF/ICSI and PGT-A (NGS) 26 co-variates analyzed • Demographics • Treatment characteristics LASSO method for variable selection • Female age, type of sperm used for ICSI, and MII oocytes (p<0.0001) Development predictive model using logistic regression analysis Internal validation by holdout method
- 20. 20 The easy way 13. Esteves et a. Front Endocrinol 2019 http://www.members.groupposeidon.com/Calculator
- 21. 21 The most optimal treatment strategy is planned with the mindset to achieve the POSEIDON marker of success GnRH analogue regimen Gonadotropin dose and drug type Trigger strategy Adjuvant therapy Combined strategies (AccuVit; Duostim, etc.) Personalized use of laboratory technology Personalized luteal phase support
- 22. 22 9. Poseidon Group. Fertil Steril 2016; 10. Humaidan et al. F1000Research 2016; 14. Haahr et al. Reprod Biol Endocrinol 2018 Gonadotropin starting dose and regimen can be determined successfully in all patient categories by Poseidon-based stratification (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
- 23. 23 When exogenous gonadotrophin is administered, the number of mature follicles recruited largely depends upon the number of follicles attaining FSH sensitivity The efficiency of a stimulation protocol must be measured by the effect of gonadotropins at the ovarian axis, and the quality of oocytes produced
- 24. 24 Modified from 17. 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) 17. Lehert P et al. Reprod Biol Endocrinol 2010; 18. Devroey et al. Fertil Steril 2012; 19. Bosch et al. Hum Reprod 2008; 20. Hompes et al. Fertil Steril 2008; 21. Andersen et al. Hum Reprod 2006
- 25. 25 Esteves, Yarali, Ubaldi et al. ESHRE 2019; submitted No detrimental effects on embryo ploidy in patients who retrieve more oocytes 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
- 26. 26 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. ESHRE 2019; submitted
- 27. 27 Administration of an inappropriately low gonadotrophin dose may lead to the growth of a low number of follicles resulting in an ‘iatrogenic’ poor or suboptimal response • Type of Gonadotropin • FSH Dose • Add LH Courtesy of Chloe Xilinas, EXCEMED Follicle-to-Oocyte Index (FOI) (No. retrieved oocytes/AFC)x100 15. Alviggi, Conforti, Esteves et al. Front Endocrinol 2018
- 28. 28 Agonist or Antagonist rFSH alone or rFSH + rLH (2:1 ratio) Agonist or Antagonist rFSH + rLH (2:1 ratio) GnRH Antagonist + Low dose rFSH (100-175 IU) GnRH Antagonist + rFSH + rLH (150:75 IU) Poseidon G1 Poseidon G2 Poseidon G3 Poseidon G4 Non Poseidon patients 22. Andersen et al. (eds.) Research Topic Frontiers in Endocrinology. In preparation It is important to use the right gonadotropin regimen and adapt it during the cycles to optimize the number of oocytes retrieved and at the same time minimize risks such as OHSS and cycle cancellation
- 29. 29 Unpublished data; Source: ANDROFERT Current Practice – Flexibility of iCOS Rec-hFSH Starting Dose Distribution (%) % cycles with Dose Adaptation after Sd5 53.4%
- 30. 30 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
- 31. 16. Conforti, Esteves, Cimadomo et al. Front Endocrinol (under review)31 PHARMACOLOGICAL INTERVENTION
- 32. 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 23. Alviggi et al. Fertil Steril 2018
- 33. 33 Target number of oocytes difficult to achieve by a single OS cycle 13. Esteves et al. Front Endocrinol 2019 Courtesy of Chloe Xilimas, EXCEMED http://www.members.groupposeidon.com/Calculator
- 34. 34 14. Haahr et al. Reprod Biol Endocrinol 2018
- 35. 35 Modified from 24. Ubaldi et al. Fertil Steril 2016 Dual stimulation Courtesy of Chloe Xilinas, EXCEMED
- 36. 36 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 Minimize Risk and Reduce Time to Live Birth
- 37. 37 iART
Editor's Notes
- Thank you for the introduction, Mr. Chairperson. Ladies and gentlemen, colleagues and friends, good morning.
- A problem we face nowadays is that the proportion of patients with advanced age is increasing steadily in our clinics. We all know that pregnancy rates are lower in these women than in their younger counterparts. However, we should also realize that the repetition of IVF treatments using a trial and error approach does not seem to help these patients much because the gap between young and older patients concerning cumulative live birth actually increases after multiple IVF cycles.
- In the era or personalized medicine, Success in IVF goes far beyond pregnancy. It should be redefined using other quality dimensions, without overlooking the patient perspective. My personal approach includes the provision of proper evaluation, counseling about the chances of success, and development of a time-limited treatment plan taking in full consideration what the patient values and preferences are.
- Most of us now use ovarian biomarkers, like AMH and AFC, to predict ovarian response to gonadotropin stimulation. Despite their unquestionable clinical value in that regard, we should not use their results to counsel our patients about their chances of success in IVF.
- What became clear though over the last years is that if we want to maximize live births we should optimize oocytes yield. However, oocyte number should be used in combination with female age since the likelihood of delivering a baby among patients with similar oocytes yield ultimately depends on female age.
- This means that the number of oocytes needed to maximize live births should be individualized taking into account female age, and more importantly, patient-oriented strategies can be used to achieve the individualized oocyte number. These aspects make the foundations, ladies and gentlemen, of the novel POSEIDON criteria that you might have heard about.
- The POSEIDON criteria propose a shift from the current terminology of POR to the concept of low prognosis. The low prognosis patients are classified into four groups based on female age, results of ovarian biomarkers, and the number of oocytes retrieved in previous cycle if that information is available.
- You may want to know why POSEIDON patients have low prognosis in IVF. The answer is very simple. Patients fitting into the POSEIDON criteria have low prognosis owing to a decreased number of oocytes, a situation that can be further aggravated by ageing and will affect cumulative live birth rates.
- I feel we should care about the new POSEIDON criteria because a significant proportion we treat in our Clinics will fit in one of the POSEIDON categories.
- In POSEIDON, based on female age, patients are classified as groups 1 and 2 if younger than 35 years, and as groups 2 and 4 if older than that. Female age is a critical element because it is related to embryo ploidy. In a study by the POSEIDON group we are presenting in this meeting, we calculated the probability of a blastocyst being euploid as a function of female age. This probability sharply declines after the age of 34, and is lower than 50% overall in older patients. This phenomenon, in combination with the already reduced ovarian reserve in older patients, leads to an increased risk of having no euploid embryos for transfer in such patients.
- This issue gets more and more complicated as the patient ages. In this study -also by the POSEIDON group- we presented this morning, we found that the % decrease in blastocyst euploidy probability progresses with every year of age. In young patients the loss is low from one year to the next year; however, it increases remarkably as the patient ages.
- Overall, POSEIDON patients can be summarized like this: In groups 1 and 3 patients are young, and therefore the risk of embryo aneuploidy is relatively low. By contrast, in groups 2 and 4 patients are older, thus increasing the risk of embryo aneuploidy. The bottom line is that in all categories, the number of embryos generated is likely to be low, thus affecting the cumulative live birth rate. You may have now realized that the prognosis of POSEIDON patients differs according to the group category.
- Big data indicates that the number of oocytes to maximize cumulative live births should be higher than 15. Although this number gives us general guidance, it might be hard to achieve in POSEIDON patients. I feel we can do better than this by determining the individualized oocyte number for each patient we treat.
- In this regard, besides the classification system, the POSEIDON initiative gives us a hand, as it introduced an intermediate marker of success in ART, namely, the ability to retrieve the number of oocytes needed to obtain at least one euploid blastocyst for transfer in each patient. We feel this is a fair outcome to offer our patients, because transfer of a euploid embryo is associated, at any given age, with implantation rates in the range of 50-60%.
- The good news is we can estimate what that number is. For this, we have to compute the results of variables more likely to affect the number of resulting embryos and their genetic competence.
- One option would be for you to look into your database and find out the results of relevant variables and then make the calculations. Another option is to use the ART Calculator, a prediction model we developed to make these calculations easy for busy doctors like us.
- The study aimed at developing a calculator to predict the POSEIDON marker of success. We analyzed clinical and embryonic data of infertile couples who underwent IVF/ICSI with PGT-A. We used the LASSO method for variable selection. The fitted model selected female age, type of sperm used for ICSI, and MII oocytes as predictors. Final predictive model developed using logistic regression analysis, and internally validated by the holdout method. Predictive ability of the model evaluated by the ROC curve (AUC=0.72) The model generates the individualized probability of blastocyst euploidy per MII oocyte, and using mathematic equations provides the minimum number of MII oocytes required for >=1 euploid blastocyst, with 95% CI interval.
- A calculator was then developed to make 2 types of prediction automatically, one pre-treatment and another post-treatment. In this movie, you can see how the calculator works, Pre-treatment, all you have to do is provide the patient age, and the type of sperm used for IVF/ICSI. Then, with a single click, the calculator provides an estimation of the number of MII oocytes needed to obtain at least one euploid blastocyst. In case the number of mature oocytes, as initially predicted, is not achieved, the calculator estimates the chances of having a euploid blastocyst using the number of MII oocytes retrieved. The ART Calculator may assist in clinical counseling and individualized treatment planning.
- We feel that the POSEIDON patient stratification and the estimation of the number of oocytes needed to obtain at least one euploid blastocyst for transfer are a perfect match. This combination can guide clinicians to select the most optimal treatment strategy with the mindset to achieve the POSEIDON marker of success, with the ultimate goal of reducing the time to live birth.
- In practical terms, the individualized oocyte number can be achieved using patient-oriented strategies. For instance, gonadotropin starting dose and regimen can be tailored according to the POSEIDON stratification.
- A crucial decision-making aspect regarding gonadotropin choice is that the number of competent follicles at the end of stimulation depends on the number of follicles attaining FSH sensitivity.
- In this regard, overwhelming evidence indicates that oocyte number is optimized by use of recombinant FSH.
- Importantly, patient-oriented gonadotropin doses aimed at retrieving more oocytes do not affect embryo genetic competence. In this ongoing study by the POSEIDON group, the age-controlled probability of a blastocyst being euploid is not affected by the size of the embryo cohort, thus confirming previous observations of no detrimental effect on embryo euploidy in patients who retrieve more oocytes.
- Our observations also indicate that use of mild or minimal stimulation as a means of improving embryo genetic competence is unsound. What matters concerning embryo ploidy is female age and not the intensity of ovarian stimulation.
- On the contrary, use of low gonadotropin dose might result in hypo-response and retrieval of fewer than expected oocyte number. This phenomenon is clearly seen in POSEIDON groups 1 and 2 patients, who despite adequate prestimulation parameters end up having poor or suboptimal oocytes yield, possibly due to use of inappropriate low gonadotropin dose or presence of polymorphisms affecting gonadotropins and their receptors.
- As I said before, and highlight here again, proper patient evaluation is key not only to identify the low prognosis patients, But also plan a treatment tailored for the patients specific needs. Naturally, use of right gonadotropin starting dose, and the possibility to adapt the dose during the cycle is essential to optimize oocytes yield while securing patient’s safety.
- In our practice, we routinely use iCOS. Different gonadotropin starting doses are chosen and adapted during the cycle –whenever needed- to increase the chances of achieving the individualized oocyte number and at the same time minimize risks such as OHSS and cycle cancellation.
- We apply the same reasoning concerning LH supplementation, trigger methods and luteal phase support.
- For instance, both non-Poseidon patients and those fitting in Poseidon groups 1 & 2 greatly benefit from pharmacological interventions as a means to increase oocyte yield and minimize risks, including OHSS and suboptimal response.
- This includes the use of not only the right FSH starting dose but also evidence-based recombinant LH supplementation, which is particularly beneficial to Poseidon’s groups 1 and 2 as well as women aged 36-39 treated with the antagonist protocol.
- However, even using the best protocol it might be hard to achieve the optimal individualized oocyte number in single stimulation. This is particularly true for patients of POSEIDON’s groups 3 and 4, who are the ones with abnormal ovarian markers.
- Consecutive ovarian stimulation in the follicular and luteal phase, know as Duostim, is an attractive strategy to be considered in patients of POSEIDON’s groups 3 and 4. The target number of oocytes might be reached quicker, thus increasing the likelihood of having at least one euploid blastocyst in the resulting embryo cohort.
- Mr. Chairman, ladies and gentlemen, I now come to the end of my presentation. I strongly believe that the use of POSEIDON-based stratification along with iCOS, with the mindset to achieve the individualized oocyte number, is the way to reduce the time to live birth. We started using this system over a year ago, and we are delighted with the results. It gives us guidance on how to most optimally treat each patient. Using the POSEIDON criteria and the ART Calculator, we are also able to provide transparent information, which helps our patients prepare both emotionally and financially for the treatment journey.
- I like to call this model “Individualized Assisted Reproductive Technology”
- I invite all of you to know more about the POSEIDON initiative and the ART Calculator. I also encourage you to join us and become a member of the POSEIDON group. Thank you very much.