1. Hong Kong Sanatorium & Hospital, China
WORLD IVM EXPERIENCE
Milton K. H. Leong, M.D.
IVF Centre
Hong Kong Sanatorium & Hospital, China

2. LEARNING OBJECTIVES
At the conclusion of this presentation, participants should be able to:
Describe the indications IVM
Outline the various IVM approaches undertaken currently.
Evaluate the IVM outcomes with regard to the treatment success rates and the babies born as a result of IVM treatment.

3. DISCLOSURE
Milton K. H. Leong, MD
None

4. Development of IVM
It was first demonstrated in 1935 that the immature oocytes have the ability to resume meiosis spontaneously when removed from the follicle.
Pincus G, Enzmann EV. J. Exp. Med. 62, (1935)
Edwards showed that in-vitro matured human oocytes could be fertilized.
Edwards RG, Bavister BD, Steptoe PC. Nature. 221(5181), (1969).

5. 1994-first IVM pregnancy with a patient’s own oocytes.
the immature human oocytes retrieved during gynecologic surgery in an oocyte donation program resulted in the first IVM pregnancy in 1991.
Cha et al., Fertil Steril 55; (1991).
1994-first IVM pregnancy with a patient’s own oocytes.
Trounson A, Wood C, Kausche A. Fertil Steril 62; (1994)

6. Development of the follicle
Stage Follicle size (mm)
Primordial
Primary
Secondary
Preantral
Early antral (*)
Antral (* +)
Preovulatory (+)
+ IVF * IVM
Gougeon, Hum Reprod 1986;1:81-7

7. Target patient group Women with high AFC;
PCOS
PCO with regular cycles
The most significant factor which determines the success of IVM treatment is the AFC of the woman
(Tan, Am. J. Obstet. Gynecol. 186; 684-9)

8. Patient selection for IVM
Suikkari 2007; Best Practice & Res Clin Obstet Gynecol 21;

9. promising outcomes are also reported in “regular cycling” women
Better prognosis if AF basale count > 7
Suikkari 2007; Best Practice & Res Clin Obstet Gynecol 21;

10. Common Indications for IVM
failure after > 6 cycles of ovulation induction
women having IVF with high AFC
repeated poor embryo quality in previous IVF cycles for no obvious reason
repeated poor responders to ovarian stimulation

11. however
low implantation rates when compared to conventional stimulated cycles.
asynchrony in the cytoplasmic and nuclear maturation of the oocyte
asynchrony in the endometrium
culture conditions

12. Various approaches to improve implantation rates in IVM
Clinical
Laboratory
Gonadotropin priming
None
hCG
FSH / FSH+hCG
Metformin
IVF / ICSI
Culture conditions

13. HCG Priming Theoretically; Promote invitro maturation
Improve pregnancy rates

14. IVM following hCG priming
Cycles of IVM 25
Age (yrs)  4.7
Oocytes retrieved  5.4
Maturation rate (%) 84
Fertilization rate (%) 87
Cleavage rate (%) 95
Embryos transferred  0.6
Clinical pregnancies - no (%) 10 (40)
Chian et al
New Engl J Med 1999; 341:1624-6

15. % of metaphase II *p < 0.05 hours of culture Chian et al
Hum Reprod 2000;

16. Fold increase in steroid accumulation in response to LH above control
Response to LH in granulosa cells from follicles < 8 mm from ovulatory women (with normal ovaries or PCO compared to anovulatory women with PCO)
Fold increase in steroid accumulation in response to LH above control
Patients
Estradiol
Progesterone
Ovulatory (normal and ovPCO)
1.0 ( );
(n = 46)a
1.0 ( );
(n = 42)c
Anovulatory (anovPCO)
1.4 ( );
(n = 17)b
1.3 ( );
(n = 20)d
a vs b, P<0.0003
c vs d, P<0.03
Willis et al., Journal of Clinical Endocrinology and Metabolism 1998; 83:

17. Duration between HCG administration and oocyte retrieval
When the durations of 35 hours vs. 38 hours between hCG administration and the oocyte retrieval were compared, the 38 h group yielded significantly higher number of mature oocytes.
In-vitro maturation rate after 24 h in the culture was significantly higher, and the clinical pregnancy rate in the 38 h group was higher compared to the 35 h group in the unstimulated cycles, 40.9% vs. 25%.
Son et al. Fertil Steril 88(Suppl. 1), S24-S25 (2007).

18. Clinical outcome in hCG-primed IVM cycles with (Group 1) and without (Group 2) MII-stage oocytes on the day of retrieval
Groups
Group 1 (n=48)
Group 2 (n=46) P
No. of oocytes collected (mean + SEM)
922 ( )
854 ( ) NS
No. of MII-stage oocytes collected (%)
135
(14.6)
No. of oocytes cultured
787
854
No. of oocytes matured in vitro (%)
500
(63.5)
535
(62.6)
Total no. of oocytes matured (%)
635
(68.8)
No. of oocytes fertilized (%)
456
(71.8)
419
(78.3)
No. of oocytes cleaved (%)
396
(86.8)
377
(90.0)
No. of oocytes transferred (mean)
178
(3.7)
173
(3.8)
No. of pregnancies (%) 23
(47.9) 13
(28.3)
<0.05
Son WY et al. RBM Online. (2008), in press

19. Hormonal Priming Regular cycling PCOS Beneficial No difference
Wynn 1998
No difference
Trounson 1998
Suikkari 2000
Mikkelsen 2005
Beneficial
Mikkelsen 2001
No difference
Lin 2003
Chian 2000

20. May improve endometrium
FSH Priming
Results are conflicting
Potential benefits:
Larger ovarian size
Easier retrieval
Higher E2 levels
More maturational competence
May improve endometrium

21. Overview of IVM treatment cycle
Withdrawal bleed
U/S scan day 2-4 to identify if PCO and measure AFC
Repeat u/s scan on day of hCG to measure endometrial thickness
s/c hCG 10,000 IU when ET 6-8 mm, largest follicle mm and oocyte retrieval 38 hours later

22. Transvaginal U/S-guided oocyte retrieval
vaginal vault cleansed with sterile water
i.v. sedation sedation with fentanyl and L.A.
19 G single single-lumen needle
reduced aspiration pressure (7.5 kPa)
multiple punctures
10 ml culture tubes with 2ml warm 0.9% saline with 2 IU heparin

23. In-vitro maturation of oocytes
GV oocytes cultured in IVM medium supplemented with 75mIU/ml FSH + LH for hrs, checked every 12 hours all MII oocytes undergo ICSI
ET day 2 or 3 following ICSI
Patients receive estradiol-17ß (micronized) immediately following OR and progesteron following ICSI

24. Endometrial Priming Endometrium is
exposed to lower
E2 levels
Dyssynchrony between phase of endometrium – matured oocyte
Endometrial preparation is necessary

25. Endometrial preparation
Endometrial thickness on day of oocyte retrieval
<6 mm mg estradiol-17ß (micronized)
6 - 8 mm mg estradiol-17ß (micronized)
>8 mm mg estradiol-17ß (micronized)
Progesterone support (50 mg I/M or 200mg tid, pv)
started following ICSI

26. Timing of Oocyte Retrieval
Dominant follicle
Early atretic
follicles
Still competent to
Embryonic development
Can be used in IVM
But; TIMING ?

27. Timing of Oocyte Collection
Russell et al. (1999)
When the leading follicle > 13 mm
Less oocytes
Less fertilization
Fewer embryos

28. Timing of Oocyte Collection
Cobo et al. (1999)
When the leading follicle < 10 mm
Higher blastocyst formation

29. Metformin in IVM 56 women, 70 cycles
Metformin, 500 mg bid for 12 weeks before the IVM treatment
HMG for 5 days and hCG 10,000 IU, 36 h prior to OPU
number of immature oocytes, oocyte maturation, fertilization and cleavage rates in were comparable to the control group
significantly higher implantation and clinical pregnancy rates were obtained in the metformin-treated group (15.3% and 38.2% respectively) compared to the controls (6.2% and 16.7%)
Wei Z et al. Fertil Steril 2007 Nov 15

30. IVM outcomes

31. Outcome of IVM cycles from literature in women with PCO/PCOS.
Authors (year)
No. of cycles
Indication
No. of ET cycles
at cleavage stage Gn
Priming
Maturation
Rate (%)
Fertilization
Implantation
Pregnancy
Rate/ET (%)
Miscarriage
Chian et al (1999) 25
PCOS
HCG 84 87 32 40 20
Cha et al (2000) 94 85
None
75.1
67.9
6.9
27.1
26.1
Chian et al (2000) 11 13
69.1
84.3
83.9
90.7
24.8
16.6
27.3
38.5
Mikkelsen and Lindenberg (2001) 12 24 9 21
FSH
44.0
59.0
69.0
70.0
21.6
33.3
57.1
Child et al (2002)
107
PCO/PCOS
76.0
78.0
9.5
26.2
Lin et al (2003) 35 33
FSH+HCG
76.5
71.9
75.8
69.5
11.3
31.4
36.4
13.0
Chian (2004)
254 NA
78.8
69.2
11.1
24.0
Soderstrom-Anttila et al (2005)
PCO: 13 7
PCOS: 18 10
9 (IVF)
5 (ICSI)
17 (IVF)
9 (ICSI)
60.6
49.2
54.3
53.2
35.0
72.4
82.5
13.3
34.5
12.5
22.2
52.9 -
50.0
Cha et al (2005)
203
187
5.5
21.9
36.8
Torre et al (2007)
138
61.7 62
10.9
24.5*
42.3
Son et al (2007)
415
106
106 (blastocyst)
74.0
78.2
80.1
80.5
9.7
26.8
28.4
51.9
21.8

32. Mean no. of oocytes retrieved
Outcome of IVM cycles from the literature in women with normal
ovaries and regular cycles.
Authors (year)
No. of cycles
No. of ET cycles
at cleavage stage Gn
Priming
Mean no. of oocytes retrieved
Maturation
Rate (%)
Fertilization
Implantation
CPR/ET (%)
M/C
Child et al. (2001)
56 (normal)
53 (PCO)
68 (PCOS) 50 52 67
HCG
5.1 ± 3.7
10 ± 5.1
11.3 ± 9
79.5
75.9*
67.7
71.6*
1.5
8.9
9.6 4
23.1
29.9 25
Mikkelsen et al. (2001)
132 83
None
3.9
60.1
72.9 NA 18
Soderstrom-Anttila et al. (2005)
92 (IVF)
100 (ICSI)
58 (IVF)
86 (ICSI)
6.3 ± 3.4
6.5 ± 3.6
66.9
54.5
35.9
67.1
22.6 15 31 21
33.3
16.7
* PCO and PCOS groups pooled together.

33. IVM for other indications

34. IVM oocyte donation 12 oocyte donors (29.7 yrs; AFC 29.7)
oocyte retrieval days 9-18 of unstimulated cycle
mean of 12.8 GV oocytes retrieved
8.67 mature oocytes and 5.9 fertilized oocytes
3.9 embryos transferred
implantation rate 19.1%; 6/12 clinical pregnancy – 4 delivered
Holzer et al
Fertil Steril 2007; 88: 62-67

35. IVM +/- natural cycle IVF and PGD
35 yr old with RM failed 2 IUI and 2 IVF
IVM offered because of PCO; 1 M II and 14 GV oocytes; ICSI performed
8 embryos, 6 biopsied, 1 embryo from MII oocyte and 1 from GV oocyte chromosomally normal for 6 autosomes and X and Y chromosome
2 ET – one blastocyst from MII oocyte and one morula from GV oocyte
ß-hCG 399 IU 14 days after ET and livebirth in May 2005
Ao et al
Fertil Steril 2006;85:

36. these oocytes can be matured in-vitro
IVM as a Rescue
Some cycles are cancelled due to
Risk of OHSS
Poor pesponse
Can IVM be a rescue ?
these oocytes can be matured in-vitro

37. IVM as a rescue + Risk of OHSS Immature oocyte retriaval IVM
10,000 IU HCG
Leading follicle = mm
Immature oocyte retriaval +
IVM
47 % CLINICAL PREGNANCY
No OHSS
Lim et al. Fertil Steril 2002

38. Immature oocyte retrieval + IVM
IVM as a rescue
In POOR RESPONSE = E2 < 1000 pg/ml
< 4 mature oocytes
Poor responders no HCG
Immature oocyte retrieval + IVM
37,5 % Pregnancy rate
Liu et al. Fertil Steril 2003

39. IVM for Fertility Preservation

40. Fertility preservation for young women
Best option; embryo cryopreservation, after ovarian stimulation followed by oocyte retrieval and fertilization of oocytes by sperm; IVF or ICSI
Probably second best;
oocyte cryopreservation after ovarian stimulation followed by oocyte retrieval

41. Ovarian stimulation is not suitable for certain cancer patients; no sufficient time and/or ovarian stimulation contraindicated
Solution ?
Trial: Retrieval of immature oocytes from unstimulated ovaries, and maturation in-vitro followed by cryopreservation of oocytes by vitrification

42. Viability and pregnancy outcome of vitrified IVM oocytes
No. of patients 20
Mean age
No. of mature oocytes retrieved 6
No. of immature oocytes retrieved
290
Mean oocyte maturation rate
No. of oocytes vitrified and thawed
215
No. of oocytes survived (mean % + SEM; range)
148 ( ; range )
No. of oocytes fertilized (mean % + SEM)
96 ( )
No. of embryos transferred (median; range)
64 (4; range 1 - 6)
No. of implantations (mean % + SEM)
4 ( )
No. of pregnancies (%)
4 (20.0)
No. of clinical pregnancies (%)
No. of ongoing pregnancies (%)
0 (0)
No. of live births (%)
Mean birth weight (grams)
3486
Chian et al, 2008, Fertil Steril, in press 42

43. Fertility preservation strategies offered for women at MRC with cancer
Chemotherapy cannot be delayed and/or hormonal stimulation contraindicated
Chemotherapy can be delayed and hormonal stimulation not contraindicated
Ovarian wedge resection or oophorectomy
Immature oocyte retrieval
Ovarian stimulation mature oocyte retrieval
Immature oocyte retrieval from ovarian tissue
IVM
Male partner available
(ICSI)
Male partner available
No male partner available
No male partner
Ovarian tissue cryopreservation
Embryo cryopreservation
Embryo cryopreservation
Ooycte vitrification
Ooycte vitrification

44. Obstetric and perinatal outcomes of the IVM pregnancies

45. Outcome of IVM, IVF, ICSI and normal pregnancies
obstetrical and perinatal outcome of 432 babies (55 IVM, 217 IVF, 160 ICSI) compared with 1,296 age-matched spontaneous pregnancies (controls) delivered at a single hospital (MUHC)
Buckett et al.
Obstet Gynecol 2007; 110:885-91

46. Perinatal outcome IVM IVF ICSI Controls p-value Twin pregnancy rate
12.0%
16.0%
14.0%
1.3%
p<0.001
Triplet pregnancy rate
4.0%
2.0%
3.0%
Mean birthweight (g)
2,812
2,826
2,801
3,289
Mean gestational age (wks) 37 36 39
Mean Apgar scores at 1 min 8
n/s
Mean Apgar scores at 5 min 9
Mean cord pH
7.29
7.30

47. Congenital abnormalities following IVM (n=55)
Major malformations 2
ompalocele
small ventricuoloseptal defect 1
Minor malformations 3
patent ductus arteriosus
congenital hip dislocation

48. Relative risk for any congenital abnormality compared with controlsRR
95% CI
IVM
1.19
0.35 – 3.25
IVF
1.01
0.52 – 1.90
ICSI
1.41
0.72 – 2.68

49. Pregnancy outcomes per clinical pregnancy after IVM, IVF and ICSI
Buckett et al
Fertil Steril 2007

50. Pregnancy Outcome in IVM
Mikkelsen et al. (2005) IVM babies
2 twins
1 NT Normal karyotype
2 preterm deliveries
1 stillbirth (42 weeks)
1 chromozomal abnormality

51. Pregnancy Outcome in IVM
Malformation:
Cha, Fertil. Steril ,3% major malformation rate
Later neuromotor development:
Soderstrom-Anttila, Hum. Reprod. 2006
))) Minor developmental delay at first year
))) No Difference in the second year

52. Deliveries and ongoing pregnancies (facts and educated guesses)
Countries
Deliveries and ongoing pregnancies
Scandinavia
150
Italy 77
France 40
Germany 20
Rest of Europe 33
Total Europe
320

53. Deliveries and ongoing pregnancies (facts and educated guesses)
Countries
Deliveries and ongoing pregnancies
Middle East 21
Japan
100
Vietnam 26
China (incl. HK) 60
Korea (Cha Hosp.) 57
Korea (Maria Cl.)
≈ 400
Rest of Asia 15
Total Asia
679

54. Deliveries and ongoing pregnancies (facts and educated guesses)
Countries
Deliveries and ongoing pregnancies
Canada
120
USA 5
Australia
Total
130

55. Deliveries and ongoing pregnancies (facts and educated guesses)
Countries
Deliveries and ongoing pregnancies
Asia
679
Europe
320
North America
125
Australia 5
Grand Total
1129
- one year ago !

56. Korea
455
Taiwan 20
Colombia 7
Canada
131
Finland 52
Turkey 8
China 58
Japan 51
Vietnam 42
Hong Kong 18
Denmark 34
Italy 56 UK
Total
930

58. Conclusions
IVM simplifies treatment, reduces costs and eliminates OHSS
IVM successful in women with high AFC
hCG increases final number of MII oocytes and rate of maturation
IVM may be helpful in women with repeated poor embryo quality in previous IVF cycles for no obvious reason, or repeated poor responders to ovarian stimulation

59. Conclusions
IVM produces CPR/C of 35%, and up to 48% in selected cases, in women up to 35 .
obstetric and perinatal outcomes of IVM pregnancies comparable with IVF and ICSI
IVM may be useful for oocyte donation or PGD
IVM may offer a chance for fertility preservation to young women with cancer and undergoing cytotoxic treatment.
IVM may not replace standard IVF but appears to play increasingly important role in ART

60. Dr. Ezgi Demirtas Reproductive Centre McGill University
Acknolwedge
Dr. Ezgi Demirtas Reproductive Centre McGill University