University Medical Centre Department for Reproductive Medicine Ljubljanska 5 SI-2000 Maribor Slovenia Accredited by EBCOG/ESHRE IVF Maribor, Lacerta D54°18’59.66’’

8.-11.September 2011, Brijuni Influence of oocyte number on IVF/ICSI results Department of Reproductive Medicine and Gynecologic Endocrinology University Clinical Centre Maribor Maribor, Slovenia Veljko Vlaisavljević E:

 Non stimulated cycle (“natural” cycle)  Minimal stimulation  Oocyte cryopreservation  Single embryo transfer  Blastocyst transfer

 Today our choice of ovarian stimulation regimen is often made using experience- based medicine  The choice of starting dose takes into account patient characteristics but is used empirically  Decision for cultivation for blastocyst stage takes into account patients age, number of oocytes, embryo quality and its number

Cochrane data (2009) From cookery to science Cochrane data (2009)  Primary outcome ( live births per couple)  Secondary outcome ( clinical pregnancy rate, multiple pregnancy rate, high order MPR, cryopreservation, failure to have any ET per couple )  Outcomes not appropriate for statistical analysis ( live births per OPU and ET, CPR/OPU&ET, implantation rate

The Cochrane Library 2009 The Cochrane Metanalysis 2009 : Live birth rate

 Aim: To evaluate the efficacy of using blastocyst stage embryo transfer in routine practice  Design: Retrospective analysis in 7059 IVF/ICSI cycles  SBT: Extended embryo culture through embrionic genome activation to select those embryos with higher implantation rate

Strategy for patients selection for blastocyst culture: NUMBER OF FLLICLES OR OOCYTES  Good responders on COH during the stimulation  Patients with 5 oocytes and more after OPU

Strategy for patients selection for blastocyst culture: FERTILIZATION  Patients with more than 4 fertilized oocytes  Patients with more than three embryos on day 3.

Duration of cultivation ( Day 3 or Day 5) and rate of cancelled embryo transfers on 4009 IVF/ICSI cycles (<10 oocytes) Number of aspirated oocytes

Cancelled embryo transfers

Day 3 ETDay 5 BT % Nonstimulated cycles (#391) 12.2 % 187 Delivery rate per cycle

No ETET 36.1% 6.9% Delivery rate/cycle = 4.3% Poor responders (one oocyte) N= Delivery rate /ET

Embryo transfer rate on D3 and D5 in patients younger than 40

Delivery rate per embryo transfer on D2 and D5 in 2002 IVF/ICSI cycles) Delivery rate per cycle

 Embryo transfer rate per cycle was higher when day 2 embryos were transferred  Expected pregnancy rate in poor responders calculated per embryo(s) available on day 2 was not affected by oocyte culture to the blastocyst stage.

(D5) Low responders (2-4 oocytes) Oocyte number afer OPU (#1276) 3 14 (D5) Delivery rate per ET 8 (D5) # oocytes ET (no ET 12.3%) 10.4% 15.7% 20.2% Delivery/ cycle

No BC for transfer eSBTSBT DBTTBT (3.8%) Normal responders (>4 oocytes/OPU) # 3131 eDBT 1135 Delivery rate (6.7%)

Delivery rate per cycle after blastocyst transfers

Double blastocyst transfer Vlaisavljevic et al. RBM Online 2008 Should the practice of double blastocyst transfer be abandoned? Vlaisavljevic et al., RBM Online, 2008;16:671. Delivery rate per transfer Twins rate

Number of embryos transferred in reimbursed cycles (IVF, Raport to Ministy of Health for 2009 Centre Maribor) 48.5%

Number of embryos transferred in cross border patients ( IVF Centre Maribor, Raport for 2009) 24.9%

Number of embryos required for transfer per baby born Embryos

Number of blastocysts required for transfer per baby born

Conclusions  eSBT is standard procedure in our centre  same number of pregnancies with smaller number of fresh transferred embryos  actual reimbursement system  successfull vitrification programme  Major barriers for eSET seems to be:  patients’ lack of knowledge

In ,2 % of all babies born in Slovenia were concieved with MAR

Symposium Naših prvih 5000 otrok Our first 5000 children Hotel Habakuk Maribor, Slovenija marec 2012

Reproductive Medicine Maribor Hospital: Veljko Vlaisavljević Vida Gavrić Lovrec Milan Reljič Vilma Kovač Lea Mlakar Polona Kores Testen Ksenija Rakić Marko Došen Nurses: Božena Rodeš Daniela Hanžel Marija Kristovič Jasna Muršič Marija Piperski Lucija Nikolič ART Laboratory: Borut Kovačič Nina Hojnik Martin Ivec Barbara Breznik Petra Robič Marjan Taborin Naca Herceg Secretary: Suzana Knuplež Marina Kokol