IVM IVF/ICSI nin YERİNİ ALACAK MI ? SLIDE 6 Standart ART Cycle Prof Dr Bülent GÜLEKLİ Dokuz Eylül Üniversitesi Tıp Fakültesi Kadın Hastalıkları ve Doğum ABD Başkanı Reprodüktif Endokrinoloji ve IVF Bilim Dalı Öğretim Üyesi

Cumulative conception rate (%) n: 4777 IVF cycles Cumulative conception rate (%) SLIDE 2 Today in vitro fertilization and embryo transfer is an established and successful form of treatment for infertility. It has been reported that for women below 34 years old the cumulative pregnancy and live birth rate after 3 cycles of IVF treatment were 63 and 61 percent respectively. These data suggest that pregnancy and live birth rates may actually be higher after IVF than natural conception in fertile couples. Such those high success rates with IVF are achieved by replacing more than one embryo which requires to get plenty oocytes Number of cycles / month Tan et.al Lancet 1990

IVF treatment with ovarian stimulation Ovarian stimulation with protocols involving GnRH agonist or antagonist in combination with gonadotrophins More oocytes available for insemination Success rates related to the number of embryos available for transfer Initially designed for tubal factor infertility, but currently used for other indications Good pregnancy rates SLIDE 6 Standart ART Cycle

Early studies on IVM of human oocytes Rock and Menkin (1944): Science, 100:105-107. Edwards (1965): Nature, 208:349-351. - matured human oocytes from antral follicles Kennedy and Donahue (1969): Science, 164:1292-1293. SLIDE 6 Standart ART Cycle ‘An alternative to the hyperstimulatory techniques is oocyte-maturation in-vitro’ – John Eppig (1989, Nat. Acad. Sci.)

Immature oocytes from unstimulated ovaries (Egg donation) Cha et al. (1991): Fertil. Steril., 55:109-113. – birth of healthy twins Cha et al. (1992): Reprod. Fertil. Dev., 4:695-701. Hwang et al. (1997): Fertil. Steril., 68:1139-1140 SLIDE 6 Standart ART Cycle

Immature oocytes from unstimulated ovaries (Oocytes from natural cycles) Paulson et al. (1992): Fertil. Steril., 57:290-293. Paulson et al. (1994): Hum. Reprod., 9:1571-1575. Thornton et al. (1998): Fertil. Steril., 70:647-650. SLIDE 6 Standart ART Cycle

Development of the follicle Follicular growth Stage Follicular size (mm) Primordial 0.03 – 0.04 Primary 0.05 – 0.06 Secondary 0.07 – 0.11 Preantral 0.12 – 0.20 Early antral 0.21 – 0.40 Antral 0.41 – 16.00 Preovulatory 16.10 – 20.00 SLIDE 6 Standart ART Cycle Gougeon, A. (1986): Hum. Reprod., 1:81-87.

Why IVM is an alternative treatment option? Recovery of immature oocytes followed by IVM is a potentially useful treatment for patients with infertility Women with polycystic ovaries (PCO) or polycystic ovarian syndrome (PCOS) have a slightly higher risk of developing ovarian hyperstimulation syndrome (OHSS) SLIDE 6 Standart ART Cycle

Advantages of IVM for infertile patients Avoidance of side effects resulting from gonadotrophin stimulation, including OHSS To simplify treatment, especially for the women Reduced cost Rescue early follicles SLIDE 6 Standart ART Cycle

Selection criteria for IVM patients Patients with PCO or PCOS, irregular or regular-cycling Antral follicle count (AFC) >20 Age <35 years 4. ‘IVM is suitable for patients with normal ovaries; suitable for MF and Unexp patients’ - acceptable preg. rates (Suikkari, Finland) 5. Other (previous poor response to IVF, oocyte donation and fertility preservation for cancer patients) SLIDE 6 Standart ART Cycle

Clinical preparation of patients for IVM Protocol 1 (no stimulation) ET (day 3) U/S OR ICSI hCG 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 SLIDE 6 Standart ART Cycle U/S rFSH 150IU/day OR ICSI ET Protocol 2 (stimulation)

IVM oocyte retrieval Oocyte retrieval 36 hrs after hCG injection Performed under general anesthesia Oocyte aspiration as per standard IVF, aspiration pressure 7.5 – 8.0 KPa (85 – 100 mm Hg) using Cook aspiraton needle. 3 – 4 follicles aspirated, one after another Follicular fluid collected in tubes containing 2 ml of warm heparinised saline soln. (heparin 2 IU/ml). The needle is then flushed with warm heparinised saline Tube containing aspirate is handed to the embryologist SLIDE 6 Standart ART Cycle

McGill Reproductive Center, Royal Victoria Hospital Priming with hCG before retrieval of immature oocytes in women with infertility due to polycystic ovary syndrome Chian RC, Gülekli B, Buckett WM, Tan SL McGill Reproductive Center, Royal Victoria Hospital Montreal, Canada SLIDE 6 Standart ART Cycle N Engl J Med 1999; 341: 1624-1626

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Chian RC et al., Hum Reprod 15: 165-170, 2000 SLIDE 6 Standart ART Cycle Chian RC et al., Hum Reprod 15: 165-170, 2000

McGill Reproductive Center, Royal Victoria Hospital, Montreal, Canada Randomized, controlled trial of priming with 10,000 IU versus 20,000 IU of human chorionic gonadotropin in women with polycystic ovary syndrome who are undergoing in vitro maturation Gulekli B, Buckett WM, Chian RC, Child TJ, Abdul-Jalil AK, Tan SL McGill Reproductive Center, Royal Victoria Hospital, Montreal, Canada SLIDE 6 Standart ART Cycle Fertil Steril. 2004 Nov;82:1458-1459

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IVM of oocytes – laboratory procedure Oocytes washed 24 – 48 hrs culture Oocytes cultured in maturation medium Mature oocyte (M-2) Insemination SLIDE 6 Standart ART Cycle 16-18 hours Cleavage Insemination (ICSI) Fertilized oocytes (2PN) Embryos for Embryo Transfer

Optimal maturation media Essential components Optimal maturation media Synchronized endometrium SLIDE 6 Standart ART Cycle

Media used for IVM Type of medium Composition Usage SAGE - IVM media kit (ART-1600) IVM Washing Hepes-buffered O.R., ICSI medium IVM Oocyte Maturation Med Maturation culture IVM Development Cleavage Embryo culture cleavage SLIDE 6 Standart ART Cycle OR Medicult IVM system (Medicult no. 82214010) LAG medium Handling medium O.R. IVM medium Maturation med. Maturation culture

Synchronized endometrium Essential components Optimal maturation media Synchronized endometrium SLIDE 6 Standart ART Cycle

Endometrial Preparation Endometrial thickness on day of OPU < 6 mm 10 - 12 mg oestradiol 6 - 8 mm 8 - 10 mg oestradiol  8 mm 6mg oestradiol Progesterone support (200mg, bid, p.v) started following ICSI SLIDE 6 Standart ART Cycle

SLIDE 6 Standart ART Cycle

SLIDE 6 Standart ART Cycle

A comparison of in vitro maturation and in vitro fertilization for women with polycystic ovaries Child TJ, Philips SJ, Abdul-Jalil AK, Gulekli B, Tan SL McGill Reproductive Center, Royal Victoria Hospital Montreal, Canada Obstet Gynecol 2002; 100:665-70 SLIDE 6 Standart ART Cycle

SLIDE 6 Standart ART Cycle

McGill Reproductive Center, Royal Victoria Hospital IN-VITRO MATURATION AND FERTILIZATION OF OOCYTES FROM UNSTIMULATED OVARIES: PREDICTING THE NUMBER OF IMMATURE OOCYTES RETRIEVED BY EARLY FOLLICULAR PHASE ULTRASOUND SCAN Tan SL, Child TJ, Gülekli B McGill Reproductive Center, Royal Victoria Hospital Montreal, Canada SLIDE 6 Standart ART Cycle Am J Obstet & Gynecol, 2002 ,186:684-9

Results No. of cycles 189 Total # of immature oocytes 1695 Viable # “ “ “ 1616 # M-II oocytes 1292 Maturation rate (%) 80.0 % # 2PN embryos 965 Fertilization rate (%) 74.7 % Mean # immature oocytes(SD) 9.0  7.0 SLIDE 6 Standart ART Cycle Am J Obstet & Gynecol, 2002 ,186:684-9

SLIDE 6 Standart ART Cycle

SLIDE 6 Standart ART Cycle

Embryology data from an IVM programme McGill DEU Average number of oocytes retrieved 14.2 13.4 Percentage of oocytes matured 76.8% 65.8% Percentage of oocytes fertilized 63.1% 64.2% Percentage of embryos cleaved 89.0% 87.5% Average number of embryos transferred 3.9 3.4 SLIDE 6 Standart ART Cycle

Outcomes from IVM programs Center No of cases Clinical Preg/ET Maria Hospital 419 32.7% (Korea, ’00-’02)a Memorial Hosp. 68 33.8% (Taiwan)a Hopital Antoine-B 17 23.5% (France, ’02-’03)a McGill Rep. Ctr. 66 32.3% (Canada, ’03)b DEU 34 28.5% SLIDE 6 Standart ART Cycle a Chian RC (2003), RBMonline 8(2): 148-66 b McGill Rep. Ctr. (2003), personal data

Sonuç PCO tespit edilen kadınlardaki daha yüksek gebelik oranları bu hastalara IVF yerine rutin tedavide IVM önerilmesini düşündürmelidir Daha önceki geleneksel IVF sikluslarına kötü cevap verenler (poor responders) ve kötü kaliteli embryolar elde edilmiş hastalarda IVM yararlı olabilir IVM özellikle polikistik overi olan ve oosit donörü olmaya hazırlanan kadınlar için avantajları nedeni ile daha caziptir, böylelikle donör sayısını artırabilir SLIDE 6 Standart ART Cycle

SLIDE 6 Standart ART Cycle Teşekkürler