1. Individualization of Cycle Control
Dr. Milton Leong
MDCM DSc (McGill)
Director, IVF Center, HKSH
Specialist in Reproductive Medicine
Adjunct Professor, OBS-GYN, McGill University

2. 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

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

4. Ovulation Stimulation
WHAT GOES AROUND COMES AROUND
*American idiom

5. Stimulated ovary

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

7. 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

8. 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

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

10. 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;
Porter et al., 1984

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

12. 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)

13. Action of GnRH agonists
Down
regulation
Action of GnRH agonists
1. Binding of GnRH leads to a post-receptor-cascade and this consecuitively to the release of LH and FSH
2. Adding of GnRH agonists will lead - because they have a higher affinitiy to the receptors and have a higher biologic potency - to binding of the agonists to the receptors instead of the natural GnRH.
3. Initially, this will lead to an increase in the receptor action, number and post-receptor-cascade with a consecutive increase in the release of LH and FSH (flare up effect).
4. After that, however, receptors are internalized, lysed, the number of receptors decreases, the post-receptor-cascade is downregulated and the stimulus to release LH and FSH will also be suppressed.
5. Downregulation and pituitary suppression will result.
GnRH
LH + FSH
GnRH - receptor
post-receptor-cascade
GnRH - agonist
Flare up effect
Pituitary suppression

14. Schematic representation of different protocols using GnRH agonists in combination with gonadotrophins for ovarian stimulation in IVF

15. The long luteal protocol
ovulation
induction
oocyte
pick up
embryo
transfer
gonadotropin administration
in an individualized dosage
start of
GnRH agonist
In the long luteal protocol a GnRH agonist depot preparation is administered during the mid-luteal phase of the preceeding cycle, or a GnRH agonist is started with a daily administration at that time.
Two weeks later, in between menstruation will start, pituitary suppression is achieved. At that time point a transvaginal ultrasound should be done to exclude cyst formation, since the flare up effect of the agonist may lead to ovarian cyst formation. If pituitary suppression has been achieved and the ovaries do not show cysts, gonadotropin stimulation can be started at that day. It will go on until hCG can be administered for ovulation induction.
Luteal phase support is necessay for these protocols.
22nd day
of previous
cycle
1st day
of gonado-
tropins
luteal phase support
14 days

16. 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

17. 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

18. 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%

19. 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%

20. Down Regulation

21. 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.

22. 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

23. Action of GnRH antagonists
1. Binding of GnRH leads to a post-receptor-cascade and this consecutively to the release of LH and FSH
2. Adding of GnRH antagonists will lead to a competitive action of GnRH and GnRH antagonists - which do not have any intrinsic activity.
3. A sudden downregulation of the post-receptor-cascade is the result with a consecutive decrease in the stimulus to release LH and FSH.
4. Pituitary suppression is achieved within a few hours without any initial flare up effect.
GnRH
LH + FSH
GnRH - receptor
post-receptor-cascade
pituitary suppression
GnRH - antagonist

24. Characteristics of GnRH antag
Ganirelix
Fully effective within 4 hours, with a half-life of about 13 hours
Cetrorelix
Fully effective within 8 hours, with a half-life of about 36 hours
R.E. Felberbaum and K. Diedrich, 1999.

25. The Cetrotide® 0.25 mg multiple dose protocol
ovulation
induction
oocyte
pick up
embryo
transfer
gonadotropin administration
in an individualized dosage
1st day
of menstruation
In the multiple dose antagonist protocol ovarian stimulation is started with the second or third day of the menstrual cycle.
Cetrotide® 0.25 mg is started on the 6th day of ovarian stimulation in the morning or on the 5th day in the evening. And is administered up to and including the day of hCG, if given in the morning.
1st day
of gonado-
tropins
luteal phase support
Cetrotide® 0.25 mg administration
daily s.c. starting on day 6 of stimulation

26. Possibilities to individualize the multiple dose protocol
To avoid a premature LH rise the administration of cetrotide® 0.25 mg on day 6 of stimulation should be the standard procedure
Using the standard procedure, a mean of 6.3 injections are necessary
This is in accordance with the package size of 7 ampoules cetrotide® 0.25 mg per patient

27. Possibilities to individualize the multiple dose protocol
Individualized administration of Cetrotide® 0.25 mg can be done
According to follicle size: only if leading follicle is  14 mm
Thereby, the multiple dose protocol can also be adapted to patients with a lower response

28. 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

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

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

31. LH and Cetrorelix 0.125mg/day
Range mIU/ml
Pre
Day 1 post
Day HCG

32. 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)

33. 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)

34. 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%

35. 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

36. 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.

37. 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: , p = 0.03
Single dose protocol
rate of OHSS: 11.1% vs. 3.5% (agonist vs. antagonist protocol) 95% CI: to 3.2
patients requiring hospitalisation: 5.6% vs. 1.8%
(agonist vs. antagonist protocol) 95% CI: to 4.1
With both Cetrotide® protocols a clear reduction of OHSS was achieved

38. 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

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

40. Problems with Ovarian Stimulation
Drug Costs
Side effects: immediate and delayed
Future long term risks
Not “User Friendly”

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

42. Individualized stimulation

43. Individualized Stimulation

44. Individualizing Stimulation

45. Individualized Stimulation

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

47. Individualizing protocols
For over responders
For low responders

48. 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

49. IVM stimulation

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

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

52. Microdose Flare Regimen (1)
Oral Contraceptive
20 mcg leuprolide cs bd x 2 d
uFSH for ovarian stimulation
Results:
↑oocytes
Less ampoules FSH
Source: Scott et al, 1994

53. Microdose Flare Regimen (2)
Oral Contraceptive
40 mcg leuprolide sc bd
4 IU/d growth hormone IM
Followed by uFSH 2 days later
Results:
↓Cancellation rate
↑E2 levels, number of oocytes
Source: Schoolcraft et al, 1997

54. Microdose Flare Regimen (3)
Oral Contraceptive
40 mcg leuprolide sc bd
uFSH starting 2 days later
Results
↓Cancellation rate
↑E2 levels, number of oocytes
Source: Surrey et al, 1998

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

56. Minimal stimulation

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

58. Delayed Stimulation

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

60. IVM stimulation

61. IVM results 2004 Aug to 2007 Jun <38 ≥38 Patients (n) 33 16
Average age
32.6
40.0
Total eggs
420 (12.7 )
160 (10.0)
MTII stage
314 (74.8%)
123( 76.9%)
Fertilization rate
254 (80.9%)
107 (87.0%)
Pregnancy rate
33.3%
37.5%
Embryos transferred 84 34
Implantation rate
14.3%
17.6%

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

63. 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

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

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

66. 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.

67. Stimulated ovary

68. Stimulated ovary