1. Dealing with ART failure – what should be the stimulation we offer
– Dr. RAMA RAJU
Dealing with ART failure – what should be the stimulation we offer
Thnak you very uch for giivng me the opertunity to share my view
chairperson

2. LITERATURE REVIEW
ART FAILURE
STIMULATION ?

3. ART FAILURE : WITH EMPTY FOLLICLES ?
Question 1

4. Empty follicle syndrome
Incidence 0.08%
False EFS
Genuine EFS
Poor responder excluded on , 4 follicle

5. Empty follicle

6. Diagnostic marker Hcg progesterone 3.5 ng/ml 5 to100 IU/L
lh >8iu/l or 15 IU/l
Gnrh

7. Etiology genuine empty follicle syndrome
Lhcgr pN400
Chromosome 2 inversion p11q21

8. False empty follicle syndrome
Hcg dose
Gnrh dose
Location of injection
Cold chain
25 degree
BMI
Timing
False empty follicle syndrome

9. Art failure due to few oocytes ?
Question
THE PREVIOUS CYCLE RESPONSE WAS NOT GOOD
Goal

10. Poor responder Afc Low Amh Low Ovarian Volume low Shorter cycles AFC
High dose of gonaatrophin
Afc Low
Amh Low
Ovarian Volume low
Shorter cycles

11. Poor responder short protocol
Rec FSH 300 Or
Hmg 450
Lh supplementation ?

12. HYPORSPONDER OPTIONS PRESENT
POOR RESPONDER
OPTIONS ARE LIMITED
HYPORSPONDER OPTIONS PRESENT

13. What is difference between HYPO vs POOR
QUESTION 4
What is difference between HYPO vs POOR
How many oocytes did I anticipate?
HYPORESPONDER
POOR RESPONDER

14. WHERE CAN I USE LH SUPPLEMENTATION?
QUESTION 4

15. HYPORESPONDER

16. On going poor responder add lh
BMI
age
afc
with optimum dose
AFC good
But not many coming up
lower rate of follicle growth
day 6
day 8
lower e2
On going poor responder  add lh

17. Lh supplementation hypo responder

18. Did I get the optimal number ?
UNENDING DEBATE
Question

19. Ovarian stimulation protocols for IVF: is more better than less
Ovarian stimulation protocols for IVF: is more better than less?  Download PDF Reproductive BioMedicine Online. Alper, Michael M.; Fauser, Bart C.. Published April 1, Volume 34, Issue 4. Pages © 2017.

20. Conventional ovarian stimulation protocols aim to maximize the number of oocytes collected to obtain more embryos, thus enabling the selection of the best quality embryos for transfer and the generation of surplus embryos that can be cryopreserved for use in additional, unstimulated cycles (Fauser et al., 2010).
Fauser, B.C., Nargund, G., Andersen, A.N., Norman, R., Tarlatzis, B., Boivin, J., Ledger, W., Mild ovarian stimulation for IVF: 10 years later. Hum. Reprod. 25, 2678–2684.

21. Current tools are too few
Follicle size number

22. Isuog 2017 sep

23. Is there a negative effect of high egg yields on embryo cryopreservation and embryo quality
Question

24. Fatemi HM et al., High ovarian response does not jeopardize ongoing pregnancy rates and increases cumulative pregnancy rates in a GnRH-antagonist protocol, Human Reproduction 2013;28(2):

25. Percentage of cycles with cryopreservation and increasing oocyte yield ( Baker et al., 2015 ). Based on Society for Assisted Reproductive Technology (SART) data from 2004–2010.

26. ART FAILURE DUE TO CANCELLED CYCLE DUE TO EXCESSIVE RESPONSE/COASTING ?
Question 6

27. Prediction Prevention Planning AMH AFC BMI ANDROGENS Ocp Progesterone
? metformin
Planning
selection of protocol

28. Hyper responder

29. EVOVLING DOSAGE NORMOGRAM, PHARMACOGENOMICS LHCGR 312 AA FSHR 29 GG
RS NO

30. Question 7 I have a 40 years failed ivf ?
Any tools for improving quality of oocytes
Question 7

31. 1 2 3 5 TH DECADE ANEUPLOIDY MITOCHONDRIAL DYSFUNCTION
Central role of oxidized coenzyme Q10 (CoQ10) as an electron and proton transporter; describes the sites of reactive oxygen species (ROS) production and the Q cycle 3 of
5 TH DECADE

32. Role of Mitochondrial DNA : MUTATION
CoQ10
STATINS
Alpha lioic acid
How long and when ?
Aging oocyte

33. Question What is duostim concept ?
Does it have a relevance in a failed ivf cycle
Question

34. Does duostim HASA REVELANCE ?
When should I cosider
Whats the evidnece

35. Does duostim HASA REVELANCE ?
When should I consider?
POOR OVARIAN RESERVE
CANCER PATIENTS 1
What's the evidence ?
VERY LIMITED 2

36. What is Lhcgr and fsh receptor polymorphism
Question 9

37. LH polymorphism phamacogenomics.
A few words

38. SMALLER DOSE

39. NO ROLE OF LH HIGH RESPONDER

40. LH NEED

41. LH polymorphism 1500 patients 2012 -2016
312 position 1
6 base pair insertion 2

42. LH polymorphism AND Lh supplemetation
wild
Heterozygous
homozygous
312 position
heterozygous
Need LH supplementation

43. THANK YOU