Is It Time To Replace Ovarian Stimulation in IVF With Alternatives Dr. Milton Leong MDCM DSc (McGill) Director, IVF Center, HKSH Specialist in Reproductive Medicine Adjunct Professor, OBS-GYN, McGill University

The first IVF Baby Drs. Steptoe and Edwards decided to abandon the use of fertility medications and try aspirating a single egg in a natural menstrual cycle. On their second attempt, Louise Brown was conceived

Ovarian Stimulation for IVF Natural Cycles Clomiphene, Clomiphene/HMG HMG FSH stimulation with agonists FSH stimulation with antagonists

Ovulation Stimulation WHAT GOES AROUND COMES AROUND *American idiom

Stimulated ovary

Technology and product development timeline: gonadotrophins Horse PMSG Pig FSH Pituitary FSH u-hMG u-FSH u-FSH r-hFSH (HP) r-hFSH FbM 1930 1940 1950 1960 1980 1990 1995 2003 Consistency Quality Local reactions Potential side-effects Antibodies Creutzfeldt–Jacob disease Local, systemic reactions Adapted from: Lunenfeld. Reprod Biomed Online 2002;4:11

Premature LH surge Poor quality No fertilization or very poor pregnancy rate Cancel egg retrieval 5-20% 5-20% All cycles treated in early 1980’s

I Review “Gold Standard” Discuss Alternatives Introduce Concept of Preparing Ovary for Egg Collection in IVF

GnRHa Long Protocol vs No Suppression meta-analysis IVF cases Odds ratios for IVF clinical pregnancy after GnRH-a versus clomiphene/FSH/hMG ovulation induction protocols

Results of first application of GnRH-agonists in the long protocol 11 patients eligible for IVF GnRH agonists s.c. (busereline) started at day of menstruation of one day before Ovarian stimulation started with HMG or purified FSH when all ovarian follicles and the endometrial lining has disappeared on ultrasound (average 15 days) One ongoing pregnancy achieved Porter RN, Smith W., Craft IL., Abdulwahid NA., JAcobs HS (1984) Induction of ovulation for in-vitro fertilization using buserelin and gonadotropins. Lancet 2; 1284-1285 Porter et al., 1984

OVARIAN STIMULATION FSH with agonist down regulation FSH with antagonists Low dose clomid/FSH stimulation Delayed stimulation IVM Natural cycles

Structure of GnRH agonists Modifications of natural GnRH to have GnRH agonistic properties 1 2 4 3 6 5 9 8 10 7 pyro (Glu) – His – Trp – Ser – Tyr – Gly – Leu – Arg – Pro – Gly – NH2 activation of the GnRH receptor regulation of GnRH receptor affinity regulation of biologic activity Modification of position 6 and 10 is typical for all GnRH agonists. This leads to a change in - GnRH receptor affinity (which is increased) - regulation of biologic activity (which is increased due to a longer half life)

Individualizing protocols Our contribution to 1. low dose short term agonist down regulation using decapeptyl 2. flexible low dose antagonist Aims: - to simplify treatment - to minimize drug usage

Decapeptyl Down Regulation 2000-2002 Total < 40 ≥ 40 # of patients 90 76 (32.9) 14(40.8) # of pregnancy 42 40 2 Pregnancy % 46.7 52.6 14 # of twins+ 10 # of babies 43 1 Miscarriage rate 16% 50%

Decapeptyl Down Regulation 2000-2003 Laboratory Data # of eggs 831 MTII 539 (67%) MTI 139 (16.7%) # of eggs ICSI 551 # of fertilized 427 Fert. % 76.4 # of E.T. 244 Mean transferred 2.7 # of preg. (F.H.) 46 Implantation rate 21%

Agonist Studies 2000 - 2001 Deca Long Luc Long Bus <40 Number of OPU 69 76 61 Number of Eggs Retrieved 881 885 726 Number of MTII 647, 73% 642, 73% 552, 76% Number of MTI 136, 15% 44, 5% 101, 14% Fertilization Rate 74% 76% 71% Mean # of Embryos Transferred per ET 3.1 3.2 2.8 Pregnancy Rate per ET 51% 49% 44% Implantation Rate 20% 22% 18% Average Age 34.4 33.2 34.9

Down Regulation

GnRH agonists Undesirable effects: Over-suppression: Also it is: LH becomes so low that it affects the production of estrogen, and possibly progesterone in the luteal phase Leads to poor response, poor pregnancy outcome due to early abortion. Also it is: Too long and too much drug use, cost, cancelled cycles and it is unnatural.

Structure of GnRH antagonists to achieve antagonistic properties of natural GnRH more modifications than only in position 6 and 10 are necessary 1 2 4 3 6 5 9 8 10 7 pyro (Glu) – His – Trp – Ser – Tyr – Gly – Leu – Arg – Pro – Gly – NH2 activation of the GnRH receptor regulation of GnRH receptor affinity regulation of biologic activity In contrast to GnRH agonists, there are more changes necessary in the structure of the natural GnRH molecule, to achieve antagonistic properties. These antagonistic properties mean: - no intrinsic effect - competitive action

Comparison: Mode of Actions Antagonists Agonists Immediate onset of actions (shortens treatment durations) Prevents hormonal withdrawal symptoms No recovery time of the pituitary long pre-treatment Hormonal (estrogen) withdrawal symptoms through desensitization of pituitary Recovery of the pituitary gonadotrophin secretion, after stopping the treatment takes about 2 weeks.

Cetrorelix 0.125mg Flexible Dose Trial Selection Criteria: 1. Previous over-suppression with agonist 2. Previous poor response 3. Previous LH surge if no agonist

BMI Distribution Mean = 21.8 (range 19-30) Mean = 21.8 (range 19-30)

# Days Cetrorelix Used Mean = 2.2 days (range 1-3)

LH and Cetrorelix 0.125mg/day Range mIU/ml Pre 1.2 - 7.8 Day 1 post 0.9 - 4.9 Day HCG 1.8 - 6

Cetrotide 0.125 mg vs 0.25 mg, 2004 – Sep 2006 0.125 mg/day Cycles 121 331 Average age 37.1±4.0 37.5±4.2 NS Days of stimulation 9.3±1.7 9.4±1.8 Total dose of FSH used (amp) 31.4±14.4 36.0±14.5 0.004 E2 on HCG day (pg/ml) 1943±941.8 2028.0±1376.0 LH on HCG day (IU/L) 3.5±3.9 2.1±1.9 0.001 Oocytes collected 1160 (9.6) 3198 (9.7) MTII 902 (77.75%) 2503 (78.26) Fertilized oocytes (fertilization rate) 770 (85.4%) 2085 (83.3%) Embryos transferred 2.8±0.8 2.9±0.8 Pregnancy rate/ET 50/121 (41.3%) 106/331 (32.0%) NS (P=0.066) Implantation rate 17.3% 13.4% NS (P=0.081)

Cetrotide 0.125 mg vs 0.25 mg, 2004 – Sep 2006 (age <40) 0.125 mg/day 0.25 mg/day P Cycles 86 215 Average age 35.1±3.1 35.2±2.9 NS Days of stimulation 9.4±1.7 9.3±1.8 Total dose of FSH used (amp) 29.6±11.9 33.2±11.6 0.016 E2 on HCG day (pg/ml) 2081.5±977.6 2040.6±1300.2 LH on HCG day (IU/L) 3.7±4.4 2.1±1.8 0.002 Oocytes collected 941 (10.9) 2240 (10.4) MTII 732 (77.78%) 1742 (77.76) Fertilized oocytes (fertilization rate) 623 (85.1%) 1448 (83.1%) Embryos transferred 2.8±0.6 2.8±0.7 Pregnancy rate/ET 43/86 (50.0%) 84/215 (39.1%) NS (P=0.083) Implantation rate 21.8% 17.4% NS (P=0.144)

Cetrotide 0.125 mg vs 0.25 mg, 2004 – Sep 2006 (age ≥40) 0.125 mg/day 0.25 mg/day P Cycles 35 116 Average age 41.6±1.7 42.0±2.3 NS Days of stimulation 9.1±1.8 9.4±1.9 Total dose of FSH used (amp) 36.0±18.6 41.1±17.7 E2 on HCG day (pg/ml) 1602.2±756.1 2003.9±1517.8 LH on HCG day (IU/L) 3.0±2.4 2.2±2.1 Oocytes collected 219 (6.26) 958 (8.25) MTII 170 (77.6%) 761 (79.4%) Fertilized oocytes (fertilization rate) 147 (86.5%) 637 (83.7%) Embryos transferred 2.9±1.1 3.0±1.0 Pregnancy rate/ET 7/35 (20.0%) 22/116 (19.0%) Implantation rate 6.9% 6.6%

The GnRH Antagonists Conclusions: Why treat 100% of patients when we are trying to prevent 5-10% LH surge Avoid over-suppression and poor response Effective in preventing LH surge Reduction of hyper-stimulation Lower costs

Antagonist vs Agonists Cet Agonist <40 ≥40 Number of OPU 371 184 171 23 Number of Eggs Retrieved 3994 1388 2126 199 Number of MTII 2984(75%) 1055(76%) 1575(74%) 152(76%) Number of MTI 526 (13%) 160 (12%) 205 (10%) 25 (13%) Number of ICSI’d 3269 1131 1729 173 Number of 2PN 2472 870 1303 126 Fertilization Rate 76% 77% 75% 73% Total # of Embryos Transferred 1039 521 532 62 Mean # of Embryos Transferred per ET 2.8 3.1 2.7 Number of Pregnancy 145 25 82 5 Pregnancy Rate per ET 39% 14% 48% 22% Implantation Rate 17% 5% 20% 10% Average Age 35.1 41.8 33.7 41.5

Problems With Ovarian Stimulation Cost Physical Suffering Immediate side effects Future side effects OHSS

Problems with Ovarian Stimulation Drug Cost Up to 40% of cost in IVF 30% of patients who would not choose IVF as fertility treatment cited cost as the deciding factor (fertility survey by YWCA HK 2002)

In 2 surveys on the population’s perception of IVF, Europe 1996 and Hong Kong 1998, 50% of infertile couples know about IVF but will not undergo treatment. The main reasons are: Religion, Cost, Worried about side effects of drugs

Problems with Ovarian Stimulation Potential Cancer Risks: Clomiphene use increased risks for Invasive and Borderline epithelial Ovarian tumors Gravid RR 1.4 Nulligravid RR 27.0 Whittemore, Harris et al 1992

Problems With Ovarian Stimulation OHSS Up to 6% of all FSH stimulated IVF cycles 1.5% Severe Compare NO OHSS with unstimulated cycles

Reduction of OHSS using Cetrotide Multiple dose protocol rate of OHSS: 6.5% vs. 1.1% (agonist vs. antagonist protocol) RR 6.2, 95% CI: 1.4 - 27.1, p = 0.03 Single dose protocol rate of OHSS: 11.1% vs. 3.5% (agonist vs. antagonist protocol) 95% CI: - 18.4 to 3.2 patients requiring hospitalisation: 5.6% vs. 1.8% (agonist vs. antagonist protocol) 95% CI: - 11.7 to 4.1 With both Cetrotide protocols a clear reduction of OHSS was achieved

Problems with Ovarian Stimulation Waste of Human Resources Excess eggs ? how to deal with Excess embryos - even worse Multiple pregnancies and their associated complications

So it is time to Individualise More User Friendly Alternatives

New Mindset Don’t think STIMULATION Think Preparing the Ovary for Egg Collection Think Patient Orientated Treatment Always Minimise Trauma to Patients

Ovum Preparation for IVF FSH/GnRH Down Regulation FSH/GnRH Antagonists Clomid, Clomid/FSH Minimal Stimulation IVM Natural Cycles

Preparation for Egg Collection Routine IVF Ovulation Stimulation FSH FSH with Agonist Down Regulation FSH with Antagonists

Preparation for Egg Collection Natural Cycle IVF Minimal Stimulation IVF In Vitro Maturation of eggs/IVF

We should stop thinking of Ovarian Stimulation, but start to consider, in all IVF cases, that we have to prepare the ovary for egg collection. Only if we do this, we can set our mind on how best we can serve our patients, in their interest and primarily in their interest.

Preparing the Ovary for Egg Collection for IVF Group A Young age No medical problem or history Previous Pregnancy ANC >5 Consider No Stimulation

Preparing the Ovary for Egg Collection in IVF Group B PCO Previous History of Poor Response Raised Day 2 FSH Consider IVM/IVF with/without stimulation

Preparing the Ovary for Egg Collection Group C No Contradiction to stimulation No previous Adverse History Normal Day 2 FSH Normal Antral Follicle Count Gold Standard: HMG/FSH with Agonist/Antagonist

Over responders Risk of OHSS Treatment options Cancel cycle Coasting No embryo transfer Convert to IVM

Over responders Prolonged Coasting Aim: To prevent hyperstimulation Practice: Coast till E2 ≤ 3000 pg/mL Sher, 1995 Start when 30% follices > 15 mm Nilsson, 1999 When 3 follicles > 17mm

Over Responders A better choice is to convert over-responders, once recognised, to IVM. IN this case, OHSS can be avoided, and pregnancy maintained, as coasting cannot guarantee relief of OHSS, and sometimes oocyte quality is compromised

Over Responders

Poor responders Age (average age of ML patient 38.7 yrs) Decrease ovarian reserve (↑D2 FSH) Decrease antral follicles count Previous ovarian surgery (Laparoscopic ovarian cystectomy)

Poor responders High dose Microdose flare Low dose clomid/FSH stimulation Delayed stimulation IVM

Poor Responders Review of randomised control trials and retrospective studies showed that increasing the FSH dosage over 300U/day has no clinical benefit. The cost of treatment and side-effects were higher Hamilton et al 2007

Minimal stimulation

Delayed Stimulation

Delayed Stimulation Including 10 cases converted to IUI 25 patients Age 30-45 41.5 D2 FSH 12.5-34 U/L 15.2 FSH 150U/D (days) 3-10 4.2 #eggs 121 2.2 % Fert 93/121 76.9% # Trans/Preg 74 (2.9) 4/25 (16%) Impl% 4/74 5.4%

Poor responders High dose Microdose flare Low dose clomid/FSH stimulation Delayed stimulation IVM

Stimulation in IVM No difference in laboratory data No difference in clinical data Makes ovum collection easier In non-PCO patients who needs IVM medical, psychological reasons slow responding IVM patients Makes IVM User Friendly

IVM stimulation

IVM results 2004 Aug to 2006 Dec <38 ≥38 Patients (n) 53 24 Average age 32.6 40.0 Total eggs 674 (12.7 ) 166 (8.3) MTII stage 504 (74.8%) 146 ( 76.9%) Fertilization rate 408 (80.9%) 113 (87.0%) Pregnancy rate 19/53 (35.8%) 8/24 (33.3%) Embryos transferred 138 (2.6) 88 (3.7) Implantation rate 23/160 (14.3%) 17.6%

IVM/IVF Selection Method

Natural Cycle IVM/IVF Maria Hospital Korea Group1: Succeed to collect oocytes from Leading Follicle Group2: Failed to collect ooyctes from Leading Follicle

Comparison of Outcomes in IVF/M, IVM and COH

Modern Trend in ART Minimize multiple pregnancies Minimize number of embryos transfer Minimize patients’ load and stress Physiological Psychological Financial

Question Is it time to revisit the aim and clinical practice of so called Controlled Ovarian Hyperstimulation. Should we be heading towards a modified direction

Answer We should look at the clinical aim of “Preparing Eggs for the treatment of IVF” rather than Ovarian Stimulation

Preparation for Ovum Collection Natural Cycles Minimal stimulation (clomiphene/FSH) IVM FSH stimulation with agonists FSH stimulation with antagonists

Conclusions: It is possible to choose stimulation procotol according to: age Ovarian status Previous history We should aim for minimal stress (in all senses) for the patients provided similar result can be obtained. Individualization of stimulation should be considered for every case.