1. (Miz Medi Hospital) Jung-Hyun Cho, M.D. (Miz Medi Hospital) Minimal Ovarian Stimulation

2. LH FSH Recruitment Selection Dominance Ovulation

3. Short Long Ultrashort LH FSH GnRH-a FSH hCG

4. Disadvantages of COH High costs of ovulatory drugs GnRH-agonist, r-FSH, r-hCGHigh costs of ovulatory drugs GnRH-agonist, r-FSH, r-hCG Physical discomforts Daily injection of gonadotropins, Blood samplingPhysical discomforts Daily injection of gonadotropins, Blood sampling Time loss Daily visiting clinic, Frequent sonographyTime loss Daily visiting clinic, Frequent sonography Risk of OHSS 5 ~ 10% of COHRisk of OHSS 5 ~ 10% of COH Long term unkown risk of ovarian cancerLong term unkown risk of ovarian cancer

5. Concept of minimal ovarian stimulation Less complex, Shorter stimulation regimens, Less expensiveLess complex, Shorter stimulation regimens, Less expensive Less patient discomfort, Less monitoring, Less programmableLess patient discomfort, Less monitoring, Less programmable Less chances of complications, Long term risksLess chances of complications, Long term risks Fewer oocytes for fertilization in vitroFewer oocytes for fertilization in vitro Fewer spare embryos for cryopreservationFewer spare embryos for cryopreservation

6. Applications of minimal ovarian stimulation Natural cycle IVF-ET Kim KR (2000)Natural cycle IVF-ET Kim KR (2000) Oral contraceptives + Clomiphene 100mg x 8 days Branigan and Ester (2000)Oral contraceptives + Clomiphene 100mg x 8 days Branigan and Ester (2000) GnRH antagonist + hMG Frydman R et al. (1999)GnRH antagonist + hMG Frydman R et al. (1999)

7. Natural cycle in IVF with GnRH antagonist M189101112131415 CetrorelixhCG hMG OPUET E 2 100 ~ 150 pg/ml Ø12 ~ 14 mm Menstrual cycle Preg rate : 32.0% /ET Hum Reprod 14(3):683,1999 Frydman R et. al

8. COHIVM

9. Hypothetic scheme of immature oocyte IVF program In vitro maturation Fertilization by ICSI Embryo development Embryo transfer Immature oocyte retrieval Biochemical assisted hatching Secretary endometrium Ovary: Immature oocytes Uterus : Midproliferative endometrium Poliferative endometrium Implantation hCG   Progesterone  E2 E2 E2 E2

10. Immature Oocytes Pick up

11. Oocyte pick up (OPU) Immature OPUCOH - OPU Follicle size5 - 10 mm15 - 25 mm Needle diameterouter 17 Gsingle 17 Ginner 20 G Flushing mediaPBSPBS heparin 40 IU/ml Pressure300 mmHg100 mmHg Follicle curettingvigorousonly suction Op. durationLongShort Anesthesiamore deeperonly sedation

12. Fertilization by ICSI oocyte Insemination-fertilization oocyte Zona hardening ICSI

13. Biochemical Assisted Hatching (BAH) by protease in conventional IVF (1994. 7. ~ 1996. 12.) - 1095 cases BAH group Control group 34.6% 29.3% 1 µg/ml pronase E in modified HTF with 0.5% BSA 24 hours before ET1 µg/ml pronase E in modified HTF with 0.5% BSA 24 hours before ET Prize paper 53rd ASRM 1997Prize paper 53rd ASRM 1997 Clinical preg. rate

14. Suggested scheme of immature oocyte program mense ovulation↓implantation↓ premordialimmaturemature In vitro maturation Fertilization by ICSI Embryo development Embryo transfer Immature oocyte retrieval Biochemical assisted hatching Secretaryendometrium Ovary: Immature oocytes Uterus : Midproliferative endometrium Proliferative endometrium Implantation hCG (10000 IU)   Progesterone (50 mg/day)  E 2 (6 mg/day)

15. Endometrial preparation in IVM-IVF-ET Mense #1OPU ICSI hCG BAHUET E 2 V 6mg/day Progesterone 50mg/day Regular mense Mid follicular phase 5,000 IU PCOEndometrial10,000 IU thickness > 8mm

16. IVM-IVF cycle E 2 (6 mg/day) P 4 (50 mg/day) Implantation windows : Natural cycle vs. IVM-IVF cycle Endometrium Re-establishment LH peak Day of OPUICSIET hCG Implantation (?) Natural cycle Ovu. Implantation Endometrium Re-establishment 10 1421 Fert. 2PNHatching 2PN Hatching 7 20 (windows) M #1

17. Maturation rate of porcine immature oocytes with coculture of CHO cells MediaCultureGV -> M II Porcine immature oocytes IVM media24 hrs34.4 % Growth media24 hrs CHO * coculture 8.7 % CHO (-) 0.0 % Growth media + IVM media CHO coculture48 hrs52.4 % CHO (-)48 hrs43.5 % * CHO : Chinese Hamster Ovary cells

18. Overall results of IVM-IVF-ET in conparison with convertional ICSI-IVF-ET Convertional IVM-IVF-ET COH-ICSI IVF-ETRegular mense groupPCO group No. of retrieved11.0 ± 0.4 *6.7 ± 0.413.6 ± 2.3o ocytes Maturaltion (%)87.162.569.5 Normal fertilization67.072.072.5 (%) Cleavage (%)84.587.989.9 Pregnancy / transfer34.216.928.3 (%) * Mean ± SEM

19. Conclusion Minal ovarian stimulationMinal ovarian stimulation -Efficiency in producing a healthy singleton pregnancy -Less complex, shorter stimulation, less risk & complications -Improved embryo selection and endometiral receptivity IVF-IVF-ETIVF-IVF-ET -To get more healthy oocytes and embryos -To get more synchronized endometrium for implantation -To improve pregnancy rate

20. IVM baby 이다은 1998. 5. 25. 이은빈 2000. 10. 9.

21. Embryo-Maternal communication = embryo hCG hCG receptor ? endometrium EGF, LIF other cytokines hCG Implantation good embryo good endometrium x