Once upon a time…

Birth after reimplantation of a human embryo

Steptoe P.C. / Edwards R.G.

Lancet 2 (1978): 366 07/78Louise Brown was born

The hypothalamic-pituitary endocrine system

brain oestrogen pituitary gland follicle stimulating hormone (FSH) ovary oestrogen 15 uterus Oestrogen

Primordial follicles  Primordial follicle is the earliest stage of follicular development  Appears in the prenatal  Consists of oocyte surrounded by single layer of squamous follicle cells

PRIMARY FOLLICLE

 Appears in baby after he was born  Consists of oocyte surrounded by single layer of squamous follicle cells  Histological appearance is like primordial follicle

OVARY

CORTEX MEDULA

Evaluation of Ovulatory Function

(Continued)  Enlarged ovarian follicle filled with fluid and a mature ooctye © 2008, March of Dimes Foundation Image provided by author. Reprinted with permission. (Figure 4)

Evaluation of Ovulatory Function

(Continued)  Mature oocyte © 2008, March of Dimes Foundation Image provided by author. Reprinted with permission. (Figure 5)

Endometrial changes in luteal phase

 Glandular secretions – nutrients, enzymes, etc  Lumina epithelial surface – mucins etc  Within luminal epithelial cells – changes in functional complexes, growth factors etc

History of ovarian stimulation



1970



1980



1990



2000

Clomifen hMG

GnRH-agonist / hMG recFSH GnRH-antagonist / hMG or recFSH long acting FSH

Correction of ovulatory dysfunction and supprtive Prevention of OHSS and multips Luteal phase support

How do we optimise??

Response assesment Choice of protocol Addition of other measures

Ovulation Induction: Clomiphene Citrate

• • • The “first line” of fertility therapy Used to treat mildly disordered ovulation and luteal phase insufficiency Establish tubal patency and sperm adequacy before use.

• • Letrozole….

XXXXXXXXXXXXXXXXX 17 10 2011 from ministry of health.

© 2008, March of Dimes Foundation

Normogonadotropic, Normoprolactinemic, Euthyroid women (WHO class 2)

 The primary indication   secondary to oligo ovulation or Anovulation  polycystic ovary syndrome.

Hypergonadotropic women

(WHO class 3)

   In contrast, with FSH concentrations at or above 40 mIU/Ml , have diminished follicular reserve , have little or   no response to clomiphene.

Ovulation Induction: Clomiphene Citrate

(Continued) • • In appropriately selected patients, 80 percent ovulate and 40 percent conceive with clomiphene • • (Imani, Eijkemans, te Velde, Habbema & Fauser, 1999).

Cumulative conception rate is 60to 70% (Dickey & Holtkamp, 1996).

• © 2008, March of Dimes Foundation

Monitering

 Size of the follicles  Estradiol levels  LH  P4 surge

Ovulation Induction: Clomiphene Citrate

(Continued) • • • • • Multiples rate is about 10 percent (Imani, Eijkemans, te Velde, Habbema & Fauser, 2002).

After 6 months, women should move on to more aggressive therapy.

© 2008, March of Dimes Foundation

What next

 Gonadotropin injection  Pregnancy rate in one large NIH study  in control group 2% /cycle  In FSH plus IUI 9%,  with timed sex 4%  Another study pushed up the FSH+IUI to 26%

Injectable Gonadotropins

 Mature ovarian follicles from gonadotropin stimulation © 2008, March of Dimes Foundation

Ovarian response profile

• Ovulatory potential • Hyper responder • Poor responder • Normal responder • Cyst former • Endometrial profile • Changing profile – wt ,precycle drugs natural course

Ovulation rate/ Cycle Alt. dose vs Daily dose

40

40 35 30 25 20 15 10 5 0

38 29 19 15 50 35 24 17

Group-I

25 19 50 33 21 14

Group II

13

1st Cycle 2nd Cycle 3rd Cycle 4th Cycle

20 15 10 5 0 45 40 35 30 25 1st Cycle 2nd Cycle 3rd Cycle 4th Cycle Group I Group II

Fixed or flexible protocol

 There was no statistically significant difference in pregnancy rate between flexible and fixed protocols.  There was a statistically significant reduction in the amount of recombinant FSH with the flexible protocol.

CONCLUSION of this study



Study strongly suggests that a alternate Day rec.FSH therapy is equally effective as daily dose therapy.



Risk of multiple pregnancies and OHSS is less then daily dose therapy and is cost effective.

How many FSH+IUI

 3 cycles  6 cycles  Till patient withdraws?

www.ecosystema.ru/eng/ 1

LH

GnRH Antagonist //Long GnRH Agonist Cycles

GnRH agonist FSH Long Agonist Protocol FSH GnRH antagonist Antagonist Protocol Flare-up Pituitary downregulation Direct gonadotropin suppression Time

Reproduced with permission from Borm and Mannaerts. Hum Reprod. 2000;15:1490.

Adapted from Hodgen. Contemp Rev Obstet Gynaecol. 1990;35:10.

GnRH-agonist and antagonist protocol

8 LHRH-agonist: daily injection/ depot/ nasal spray G OPU d -14 HCG 6 „ long protocol “ 4 Ampoules HMG 2 0 -16 -14 -12 -10 -8 -6 -4 -2 0 Menses 2 4 6 ET 8 10 12 14 16 17 day of cycle „Lübeck protocol“ antagonist 8 d 6 HCG 6 OPU ET 4 Ampoules Gonadotropins 2 0 0 Menses 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 day of cycle

Complications of FSH use

 Multiples  in follicles  in fetuses.

Prison sentence up to three years or financial penalty for § 1, Abs. 1, Nr. 3

„a person transfering more than 3 embryos to the womb in the course of one treatment cycle“

§ 1, Abs. 1, Nr. 5

„a person fertilizing more oocytes than he or she intends to tranfer in the course of one treatment cycle“

Trigerring

 3 or more follicles 17 mm  Expect cohort to be more heterogenous

Poor responders

 Are always poor responders  No difference between flexible and fixed protocol

Cycle programming

 Delay of trigger can be deleterious No difference in CPR in a day of delay 25% vs 35%, on going pregnancy rate when trigerring 2 days vs 3 days after follicles are 17 mm respectively

Orgalutran Phase 3 Trials: Duration of FSH Stimulation

12 10 10 10 9 8 8 6 4 2 0 EU trial NA trial

Out and Mannaerts. Hum Fertil. 2002;5:G5.

9 EU/ME trial 11 Orgalutran Buserelin Leuprolide Triptorelin

Orgalutran Phase 3 Trials: Amount of recFSH Required

2,500 2,000 1,800 1,800 2,025 1,500 1,500 1,350 1,800 1,000 500 0 EU trial NA trial EU/ME trial

Out and Mannaerts. Hum Fertil. 2002;5:G5.

Orgalutran Buserelin Leuprolide Triptorelin

Orgalutran Phase 3 Trials: Number of Oocytes and Good Quality Embryos

16 Oocytes 14.1

10 9 14 Good Quality Embyros Orgalutran Buserelin 8 12 11.7

Leuprolide 7 9.7

Triptorelin 10 9.6

6 8.7

7.9

8 5 4.8

4.3

4 6 3.3

3.5

2.9

3 2.7

4 2 2 1 0 0 EU trial NA trial EU/ME trial EU trial NA trial EU/ME trial

EU = European; NA = North American; ME = Middle East.

Out and Mannaerts. Hum Fertil. 2002;5:G5.

Orgalutran Phase 3 Trials: Ongoing Pregnancy Rate per Started Cycle

40 35 30 25.7

30.8

36.4

31 33.9

Orgalutran Buserelin Leuprolide Triptorelin 25 20.3

20 15 10 5 0 EU trial NA trial EU/ME trial

Out and Mannaerts. Hum Fertil. 2002;5:G5.

 Orgalutran vs GnRH Agonist: Success Rates Vary Between Centers

45 40 35 30 25 20 15 10 5 0 38 38.8

14.6

31.3

30.8

36.4

9 USA sites (n=204) 2 Canadian sites (n=93) Overall (n=297) Values represent unadjusted means

Data on file, North American Ganirelix Study Group.

Orgalutran Leuprolide

Orgalutran vs GnRH Agonist: Success Rates Better in Centers With Experience

40 27.6

24.2

23.6

25.7

30 20.3

20 16.5

Orgalutran Buserelin 10 0 10 sites with experience (n=337) 10 sites without experience (n=363) Overall (n=700)

Values represent unadjusted means and SE.

Borm and Mannaerts. Hum Reprod. 2000;15:1490.

GnRH Antagonists Are Associated With More Favorable Outcomes vs GnRH Agonists Among Women at High Risk for OHSS Investigator-driven, prospective observational study of women (N=87) at high risk for OHSS, who were treated with a GnRH antagonist protocol following a previous cycle with a GnRH agonist protocol

P

=0.003

100 96.6

90 80 70 60 50 40 30 20 10 0

P

<0.001

56.3

32.2

P

<0.001

43.7

67.8

76.3

GnRH agonist GnRH antagonist

P

=0.006

27.6

11.5

Canceled cycles Oocyte retrievals Embryo transfer OHSS

Ragni et al. Hum Reprod. 2005;20:2421.

Endometrial abnormalities in stimulated cycles

 Advanced endometrial maturation by 2-4 days  This effect not seen if frozen embryos transferred in natural cycle.

Antagonist

vs Long GnRH Agonist: Effects on the Endometrium  No relevant alteration in endometrial thickness  Endometrial dating, estrogen and progesterone receptor expression, and endometrial surface structure were unaffected  Agonist was associated with indications of an arrest in endometrial development  Expression of “window of implantation” genes with antagonist treatment more closely paralleled the pattern observed during a natural cycle compared with agonist Simon et al. Hum Reprod. 2005;20:3318.

Best Practices for GnRH Antagonist Protocols: Evidence Does Not Support Supplementation of LH Activity

Bosch et al 1 Meta-analysis 2 15 10 5 0 40 35 30 25 20 35

P

=0.61

32.1

40 35 30

P

=NS 29.5

31.7

hMG recFSH 25 20 15 10 5 0 recFSH + rLH recFSH

1. Bosch et al. Hum Reprod. 2008;23:2346.

2. Baruffi et al. Reprod Biomed Online. 2007;14:14.

GnRH Antagonist Strategy Is Associated With a Lower Dropout Rate vs Long GnRH Agonist Strategy

Continuation of therapy following each cycle 100 95.9% GnRH antagonist plus SET GnRH agonist plus DET 88.3% 90 80 93.7% 78.6% 70 60

P

=0.034

50 0 1 Cycle number

SET = single embryo transfer; DET = double embryo transfer.

Adapted from Verberg et al. Hum Reprod. 2008;23:2050.

2 75.9% 3

GnRH Antagonist and Long GnRH Agonist Strategies Result in Comparable Cumulative Pregnancy Rates

Proportion of pregnancies leading to cumulative term live birth within 12 months after starting IVF

60

GnRH agonist with DET GnRH antagonist with SET

40 20

Singleton term live birth

0 0 3 6

Months since randomization

9 12 Adapted from Heijnen et al. Lancet. 2007;369:743.

GnRH Antagonist and GnRH Agonist Strategies Result in Shorter Treatment, Better Safety, and Lower Cost

GnRH GnRH Antagonist (n=444) Agonist (n=325) P Value

Days of injections 8.5

25.3

<0.0001

Days of stimulation Total dose of FSH (IU) Incidence of OHSS (%) Mean total costs 8.3

1,307 1.4

€8,333 11.5

1,832 3.7

€10,745 <0.0001

<0.0001

0.04

0.006

Heijnen et al. Lancet. 2007;369:743.

The low dose protocol

 Indication - PCOS patients  Start with 37.5u rFSH  Scan after a week  If no improvement increase by 37.5  Maintain dose if dominant follicle grows  Trigger with agonist

Low dose FSH protocol

 Weekly increment if no increase in size

107 75 37.5 u

PCOS-The soft protocol solution  CC- D2- D5 days  D6 HMG/FSH 50-150 u /day  Lead follicle 13mm, or 6 follicles of 1.2,E2 400ng  Add antagonist 0.25mgm/day  Follicle – 17mm  Trigger -1mgm of agonist/HCG 5000iu  IUI or ART 36 hrs later Cardone FS2003

Newer forms of isomers.

 it is unlikely that isoforms of FSH with half-lives longer than present preparations would have much clinical application except for stimulation of spermatogenesis. For induction of ovulation, a range of products with relatively short half-lives would permit more sensitive manipulation of the therapeutic dose and facilitate achieving mono-ovulation. The current preparations of FSH are likely to continue to dominate clinical use for ovarian stimulation prior to IVF.

Stimulation of follicle development with FSH preparation of differing half-lives (t1/2) to achieve ovulation of a single follicle (Adapted from Baird, 1993).

Baird D T Hum. Reprod. 2001;16:1316-1318

© European Society of Human Reproduction and Embryology

FSH-CTP

long acting FSH

follicle aspiration after 36h 10000 IE hCG 1 2 3 4 5 6 7 8 9 10 11 12 13 14 ….

GnRH-Antagonist

LF 10 mm LF 14 mm LF 17mm



Dr Muhammad El Hennawy

 

Ob/gyn specialist 59 Street - Rass el barr – dumyat - egypt



www.mmhennawy.8m.com



Mobile 0122503011

Ovarian Cortical Strips Transplantation

Orthotopic Whole Fresh Ovary Microsurgical Transplantation  (A) Depiction of donor oophorectomy.

 (B) Microsurgical isolation of donor ovary blood supply.

 (C) End-to-end anastomosis of ovarian blood vessel.  (D) Completed anastomosis of ovarian artery and veins.

Why? !

    Ovarian tissue transplantation is an option for women who want to protect their fertility and hormones while they undergo treatment for cancer , including chemotherapy and radiotherapy For women undergoing oophorectomy (in severe or recurrent ovarian disease such as cysts, benign tumours or endometriomas or ovarian pain), accidental bilateral salpingo oophorectomy for huge uterine fibroids and dense pelvic adhesion--- not only to maintain endocrine functions but also for fertility preservation Ovarian dysgenesis with missing normal ovarian complement and premature ovarian failure has come in the forefront.

Women in their 20s or 30s could theoretically have an ovary removed and frozen, and then have it reimplanted years later when they are ready to have children as “ We are in the middle of an infertility epidemic”

Heterotopic Whole Fresh Ovary Microsurgical Transplantation  The patients' own ovaries were transplanted to their upper limb to avoid the effect of pelvic radiation as a treatment of Hodgkin lymphoma in one patient and uterine cervical cancer in the other.

How To Prepare Ovarian Cortical Strips          Under general anesthesia One ovary was removed laparoscopically or mini laparotomy, The whole ovary was transferred to a Petri dish Under Microscope . dissection with a scalpel and toothed forceps. It was felt important to prepare a cortical tissue slice no thicker than ~1.0 mm to facilitate rapid revascularization While keeping the tissue constantly irrigated with ice-cold medium Its cortex was prepared in 8 strips of 50x 5 x 1 to 2 mm DEPENDING ON PATIENT SIZE: from 5 to 15 pieces The cortex of each ovary was cut into pieces 10 × 10 × 1 mm. ---- 2 or 3 pieces for woman or The cortex of each ovary was cut into pieces 15 × 5 × 1 mm. ---- 3 or 4 pieces for woman

Transplantation of fresh ovarian cortical pieces under the tunica albuginea    Three pairs of 5-mm transverse incisions were made in the left ovary through the tunica albuginea With blunt dissection, cavities were formed beneath the cortex for each of the three strips. Each piece of thawed ovarian tissue (1.5 by 0.5 cm in area and 0.1 to 0.2 cm in thickness) was gently placed in a cavity, and the incisions were closed with 4/0 Vicryl sutures.

In The Future

 Women in their 20s or 30s could theoretically have an ovary removed and frozen, and then have it re-implanted years later when they are ready to have children as “ We are in the middle of an infertility epidemic”

The newer cinderella

Rec HCG Rec LH

Antagonist

Good follicle and poor endometriun

Individualisation is the key

drug No.of

trials PT IUI additives

OOCYTE DEFECTS

FERTILISATION DEFECTS

AND MILES TO GO …..

Last words…..

 Self-limiting disease of the luteal phase  The best preventive method is to adapt the treatment and to closely monitor patients at risk Garbba Rakshambigai Fertility Centre

ThANK YOU…..

Garbba Rakshambigai Fertility Centre