1. In-vitro maturation: patient selection and results Aygul Demirol Assoc Prof, Medical Director GURGAN CLINIC IVF Center, Ankara-Turkey

2. In-vitro maturation (IVM) Immature oocyte retrieval and subsequent oocyte maturation in vitro without any ovarian stimulation Immature oocyte retrieval and subsequent oocyte maturation in vitro without any ovarian stimulation

3. IVM (in-vitro maturation) In 1991, Cha et al. reported a pregnancy from IVF with oocytes obtained from ovariectomy specimens and matured in culture (healthy triplet girls) (Cha KY, Fertil Steril 1991)

4. Trounson et al. reported the birth of a normal baby with IVM of immature oocytes from a polycystic ovary syndrome (Trounson Fertil Steril 1994) IVM (in-vitro maturation)

5. There have been more than 1000 births of babies with IVM procedures, including in patients with PCOS (Chian RC) BUT, IVM has not become mainstream in IVF, with ovulation induction cycles with oocyte retrieval of mature (MII) oocytes still the highly favored protocol.

6. Why IVM ? Reduced cost Reduced cost Avoiding OHSS Avoiding OHSS Simplification of treatment compared with conventional IVF-ET

7. IVM Indications PCOS PCOS High responders High responders IVF/IVM IVF/IVM Fertility preservation Fertility preservation Donation cycles Donation cycles Delayed responders Delayed responders Male infertility Male infertility Poor responders Poor responders

8. 2-12 mm follicles

9. In general clinical pregnancy rate 30-35% clinical pregnancy rate 30-35% implantation rate 10-15% implantation rate 10-15% (R.C. Chian RBM Online, 2004)

10. IVM low implantation rates when compared to conventional stimulated cycles. 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

11. IVM is based on the treatment of Two main groups of patients Two main groups of patients –With PCO ( –With PCO (have irregular, mostly anovulatory cycles and are at increased risk for OHSS because of their higher sensitivity to gonadotropins) –With normal ovaries ( –With normal ovaries (may wish to avoid the side-effects of hormone injections)

12. How to maximize IVM results by optimizing clinical management Patient selection criteria-best candidates Patient selection criteria-best candidates –Under 35 years of age –PCO/PCOS

13. Patient management-I Baseline TV-USG (day 2, 3) Second USG (between day 6 and day 9) (for follicular and endometrial assessment) HCG priming 36 hours prior to egg collection

14. Patient management-II IVM ovum aspiration needle, single or double lumen, 19 G, 35 cm IVM ovum aspiration needle, single or double lumen, 19 G, 35 cm Aspiration pressure 85-100 mmHg Aspiration pressure 85-100 mmHg All visible follicles are aspirated All visible follicles are aspirated

15. Patient management-III Priming with FSH or HMG ? Priming with FSH or HMG ? Priming with HCG ? Priming with HCG ?

16. FSH Priming Results are conflicting Results are conflicting Potential benefits: Potential benefits: –Larger ovarian size –Easier retrieval –Higher E2 levels –More maturational competence May lead to improved endometrial priming

17. HCG Priming Theoretically HCG priming Theoretically HCG priming –Promote invitro maturation –Improve pregnancy rates However the exact mechanism of HCG on small follicles is still unclear

18. HCG Priming First prospective study First prospective study Chian et al. (2000) Increased oocyte maturation Increased oocyte maturation High clinical pregnancy rate High clinical pregnancy rate ( 36 %)

19. hCG Priming In-vitro maturation rate is faster in oocytes obtained from hCG primed IVM oocytes. In-vitro maturation rate is faster in oocytes obtained from hCG primed IVM oocytes. (Chian et al.,Human Reprod,2000 ; Son et al., RBM Online,2006) (Chian et al.,Human Reprod,2000 ; Son et al., RBM Online,2006) - Hastens the the oocyte maturation in-vitro - Hastens the the oocyte maturation in-vitro - Makes the oocyte retrieval easier - Makes the oocyte retrieval easier Mature oocyte on the day of retrieval is higher Mature oocyte on the day of retrieval is higher (Son et al.,Hum.Reprod,2002) (Son et al.,Hum.Reprod,2002) Higher fertilization,cleavage and blastocyt development rates in IVM cycles Higher fertilization,cleavage and blastocyt development rates in IVM cycles Number of good quality blastocysts higher (40% vs 23.3%) (Son et al.,RBM Online,2008) Number of good quality blastocysts higher (40% vs 23.3%) (Son et al.,RBM Online,2008)

20. Lab management-I Lab management-I Determination of cumulus-oocyte complexes (COCs) (special sliding technique-after using cell strainer) Determination of cumulus-oocyte complexes (COCs) (special sliding technique-after using cell strainer) The immature COCs are incubated in culture dish containing 1 ml oocyte maturation medium supplemented with a final concentration of 75 mIU/ml FSH and 75 mIU/ml LH The immature COCs are incubated in culture dish containing 1 ml oocyte maturation medium supplemented with a final concentration of 75 mIU/ml FSH and 75 mIU/ml LH for SAGE medium for SAGE medium

21. For MediCult medium, preincubation in LAG medium (2-3 hours) For MediCult medium, preincubation in LAG medium (2-3 hours) Transferring into IVM final maturation medium (9 ml IVM medium is added 1 ml patient serum, 10 µ l pregnyl, 100 µ l FSH) Transferring into IVM final maturation medium (9 ml IVM medium is added 1 ml patient serum, 10 µ l pregnyl, 100 µ l FSH) Lab management-II Lab management-II

22. Stripping oocytes 24 hours after culture Stripping oocytes 24 hours after culture Twenty for hours after maturation additional 24 hours for immature COCs Twenty for hours after maturation additional 24 hours for immature COCs Mature oocytes are subjected to ICSI Mature oocytes are subjected to ICSI Embryo maintenance medium for SAGE Embryo maintenance medium for SAGE ISM1 for MediCult ISM1 for MediCult Lab management-III Lab management-III

23. Endometrial priming 17-β-oestradiol starts on the day of OPU (2 mg orally, three times daily and continue until pregnancy test) 17-β-oestradiol starts on the day of OPU (2 mg orally, three times daily and continue until pregnancy test) Two days after OPU, intravaginal progesterone suppositories 600-800 mg, daily and continue until pregnancy test) Two days after OPU, intravaginal progesterone suppositories 600-800 mg, daily and continue until pregnancy test)

24. Clinical outcome for PCO/PCOS Jurema MW. Fertil Steril 2006;86:1277–91.

25. Clinical outcome for normal ovaries Jurema MW. Fertil Steril 2006;86:1277–91.

26. Pregnancies and deliveries after transfer of human blastocysts derived from in vitro matured oocytes in IVM ( PCO(S) ) (Blastocyst vs cleavage ET)

28. The abortion rate, gestational age and birth weight at delivery, and obstetric complications of pregnancies conceived by IVM-ET in women with PCOS were comparable with those of other women with PCOS being treated by conventional IVF-ET (Fertil Steril, 2005)

29. CONCLUSION: Compared with IVF and ICSI, IVM is not associated with any additional risk. (Obstet Gynecol 2007;110:885–91)

30. Outcome of the IVM cycles (sept 2005-jan 2010) GURGAN CLINIC IVF Center Ankara, Turkey

31. n%mean Mean age30.2 Cycles321 Cycles with oocytes 321100 Oocytes retrieved 27258.7 24 h maturation Oocytes reaching MII125347.14.2 Oocytes fertilized(2PN)98979.23.08 Embryos cleaved 89090.1 48 h maturation Oocytes reaching MII40815.31.2 Oocytes fertilized (2PN) 30174 Embryos cleaved21070.2

32. n% mean transfer and outcome Cycles with embryo transfer 28890.4 Embryos transferred 806 2.8 Biochemical pregnancies/transfer 10336.1 Clinical pregnancies/transfer 7827.1 Implantation rate 13.4 Ongoing pregnancies 41 Live birth16 Abortion rate2126.9

33. Immature oocyte after oocyte pick-up

34. Mature oocytes after denudation & ICSI

35. Fertilised (2 PN)oocytes

36. Cleavage stage (Day 2) embryos

38. Blastocyst stage (Day5)

39. PREGNANCIES IN TURKEY FOLLOWING IN VITRO OOCTYE MATURATION Aygul Demirol, Tamer Sari, Bagdagul Girgin, Erkin Kent, Suleyman Guven, Timur Gurgan 2007, GORM *Two women with history of infertility and PCOS underwent in vitro maturation (IVM) program without controlled ovarian hyperstimulation. The patients were primed with 10.000 IU HCG 36 h before oocyte retrieval. Oocytes-cumulus masses were matured in IVM medium. The matured oocytes were fertilized by ICSI and embryo transfer was performed on day 3

40. accepted

44. IVM for a Second Chance Recent reports: Recent reports: Risk of OHSS Risk of OHSS Immature oocyte retriaval + IVM instead of cancellation 47 % CLINICAL PREGNANCY No OHSS Lim et al. Fertil Steril 2002 10,000 IU HCG Leading follicle = 12-14 mm

45. Natural Cycle + IVM But natural cycle yields only 1 single follicle But natural cycle yields only 1 single follicle For other non dominant follicles For other non dominant follicles IVM may be an option Because IVM is possible even if the dominant follicle is selected Thornton 1998 Fertil Steril

48. Thank you for their help and support Ri-Cheng Chian, McGill Reproductive Center, Montreal, Canada Ri-Cheng Chian, McGill Reproductive Center, Montreal, Canada Mette Munk, Jyllinge, Denmark Mette Munk, Jyllinge, Denmark and others… and others…