Once upon a time…

07/78Louise Brownwas born

Birth after reimplantation of a human embryoSteptoe P.C. / Edwards R.G.Lancet 2 (1978): 366

The hypothalamic-pituitaryendocrine system

brain

pituitary gland

follicle-stimulating hormone (FSH)

ovary

oestrogen

oestrogen

uterus

Oestrogen

15

Primordial folliclesPrimordial follicle is the earliest

stage of follicular developmentAppears in the prenatal Consists of oocyte surrounded by single

layer of squamous follicle cells

PRIMARY FOLLICLEAppears in baby after he was bornConsists of oocyte surrounded by single

layer of squamous follicle cellsHistological appearance is like

primordial follicle

OVARY

MEDULA

CORTEX

© 2008, March of Dimes Foundation

Enlarged ovarian follicle filled with fluid and a mature ooctye

Evaluation of Ovulatory Function (Continued)

Image provided by author. Reprinted with permission. (Figure 4)

© 2008, March of Dimes Foundation

Mature oocyte

Evaluation of Ovulatory Function (Continued)

Image provided by author. Reprinted with permission. (Figure 5)

Endometrial changes in luteal phase Glandular secretions – nutrients, enzymes,

etc

Lumina epithelial surface – mucins etc

Within luminal epithelial cells – changes in functional complexes, growth factors etc

History of ovarian stimulation1970 Clomifen

hMG

1980 GnRH-agonist / hMG

1990 recFSHGnRH-antagonist / hMG or recFSH

2000 long acting FSH

G

How do we optimise??

© 2008, March of Dimes Foundation

Ovulation Induction: Clomiphene Citrate

• The “first line” of fertility therapy• Used to treat mildly disordered ovulation and

luteal-phase insufficiency• Establish tubal patency and sperm adequacy

before use.

• Letrozole….XXXXXXXXXXXXXXXXX• 17 10 2011 from ministry of health.

The primary indication secondary to oligo ovulation or Anovulationpolycystic ovary syndrome.

Normogonadotropic, Normoprolactinemic, Euthyroid women (WHO class 2)

Hypergonadotropic women (WHO class 3)

In contrast, with FSH concentrations at or

above 40 mIU/Ml , have diminished follicular

reserve, have little or

no response to clomiphene.

© 2008, March of Dimes Foundation

Ovulation Induction: Clomiphene Citrate (Continued)

In appropriately selected patients,• 80 percent ovulate and • 40 percent conceive with clomiphene

• (Imani, Eijkemans, te Velde, Habbema & Fauser, 1999).

• Cumulative conception rate is 60to 70%• (Dickey & Holtkamp, 1996).

Monitering Size of the follicles

Estradiol levels

LH

P4 surge

© 2008, March of Dimes Foundation

Ovulation Induction: Clomiphene Citrate (Continued)

• Multiples rate is about 10 percent• (Imani, Eijkemans, te Velde, Habbema & Fauser, 2002).

• After 6 months,• women should move on to • more aggressive therapy.

What nextGonadotropin injection

Pregnancy rate in one large NIH study in control group 2% /cycleIn FSH plus IUI 9%,with timed sex 4%Another study pushed up the FSH+IUI to

26%

© 2008, March of Dimes Foundation

Mature ovarian follicles from gonadotropin stimulation

Injectable Gonadotropins

Ovarian response profile

• Ovulatory potential• Hyper responder• Poor responder• Normal responder• Cyst former• Endometrial profile

• Changing profile – wt ,precycle drugsnatural course

0

5

10

15

20

25

30

35

40

Group-I Group II

1st Cycle2nd Cycle3rd Cycle4th Cycle

50

35

24

17

50

33

21

14

38

29

19 1

5

40

25

19

13

05

1015202530354045

1st Cycle 2ndCycle

3rdCycle

4th Cycle

Group IGroup II

Fixed or flexible protocolThere was no statistically significant

difference in pregnancy rate between flexible and fixed protocols.

There was a statistically significant reduction in the amount of recombinant FSH with the flexible protocol.

CONCLUSION of this studyCONCLUSION of this study Study strongly suggests that a alternate Day rec.FSH therapy is equally effective as daily dose therapy.

Risk of multiple pregnancies and OHSS is less then daily dose therapy and is cost effective.

How many FSH+IUI3 cycles6 cyclesTill patient withdraws?

www.ecosystema.ru/eng/

1

GnRH Antagonist //Long GnRH Agonist Cycles

GnRH antagonist

FSH AntagonistProtocol

GnRH agonist

FSH Long AgonistProtocol

Flare-up

Pituitary downregulatio

n

Directgonadotropinsuppression

LH

Time

Reproduced with permission from Borm and Mannaerts. Hum Reprod. 2000;15:1490.Adapted from Hodgen. Contemp Rev Obstet Gynaecol. 1990;35:10.

0

2

4

6

8

AmpoulesGonadotropins

d 6

Menses

antagonist

OPU

HCG

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

ET

day of cycle

-16 -14 -12 -10 -8 -6 -4 -2 0 2 4 6 8 10 12 14 16

0

2

4

6

8

Ampoules HMG

GOPU

d -14

LHRH-agonist: daily injection/ depot/ nasal spray

Menses

ET

HCG

17 day of cycle

„long protocol“

„Lübeck protocol“

GnRH-agonist and antagonist protocol

Complications of FSH useMultiples

in follicles

in fetuses.

§ 1, Abs. 1, Nr. 5„a person fertilizing more oocytes than he or she intends to tranfer in the course of one treatment cycle“

§ 1, Abs. 1, Nr. 3„a person transfering more than 3 embryos to the womb in the course of one treatment cycle“

Prison sentence up to three years or financial penalty for

Trigerring 3 or more follicles 17 mmExpect cohort to be more heterogenous

Poor respondersAre always poor responders

No difference between flexible and fixed protocol

Cycle programmingDelay of trigger can be deleterious

No difference in CPR in a day of delay

25% vs 35%, on going pregnancy rate when trigerring 2 days vs 3 days after follicles are 17 mm respectively

9

8

9

10 10

11

0

2

4

6

8

10

12

EUtrial

NAtrial

EU/MEtrial

Days

of

FS

H

stim

ula

tion Triptorelin

BuserelinLeuprolide

Orgalutran

Out and Mannaerts. Hum Fertil. 2002;5:G5.

1,500

1,800

1,350

1,800

2,025

1,800

0

500

1,000

1,500

2,000

2,500

Triptorelin

BuserelinLeuprolide

IU o

f F

SH

req

uir

ed

EUtrial

NAtrial

EU/MEtrial

Orgalutran

Out and Mannaerts. Hum Fertil. 2002;5:G5.

EUtrial

NAtrial

EU/MEtrial

Triptorelin

BuserelinLeuprolide

8.7

11.7

7.9

9.7

14.1

9.6

0

2

4

6

8

10

12

14

16

3.3

4.3

2.7

3.5

4.8

2.9

0

1

2

3

4

5

6

7

8

9

10

EUtrial

NAtrial

EU/MEtrial

EU = European; NA = North American; ME = Middle East.Out and Mannaerts. Hum Fertil. 2002;5:G5.

Orgalutran

Nu

mb

er

Nu

mb

er

Good Quality Embyros

Oocytes

20.3

30.8 31

25.7

36.433.9

0

5

10

15

20

25

30

35

40 Orgalutran

Triptorelin

BuserelinLeuprolide

EUtrial

NAtrial

EU/MEtrial

On

goin

g p

reg

nan

cy

rate

(%

)

Out and Mannaerts. Hum Fertil. 2002;5:G5.

If results from the 2 sites with outlier results are excluded, pregnancy rate is similar for antagonist and agonist cycles

38

14.6

30.8

38.8

31.336.4

05

1015202530354045

9 USA sites(n=204)

2 Canadian sites (n=93)

Overall(n=297)

Leuprolide

Values represent unadjusted means

Orgalutran

On

goin

g p

reg

nan

cy

rate

per

att

em

pt

(%)

Data on file, North American Ganirelix Study Group.

20.3

25.7

0

10

20

30

40

Overall

Orgalutran

Buserelin

On

goin

g

pre

gn

an

cy

rate

p

er

att

em

pt

(%)

24.2 23.6

10 sites withexperience

(n=337)

10 sites without

16.5

27.6

experience(n=36

3)(n=700

)

Values represent unadjusted means and SE.Borm and Mannaerts. Hum Reprod. 2000;15:1490.

GnRH Antagonists Are Associated With More Favorable Outcomes vs GnRH Agonists Among Women at High Risk for OHSS

56.3

43.7

76.3

27.632.2

67.8

96.6

11.5

0

10

20

30

40

50

60

70

80

90

100

Canceledcycles

Oocyteretrievals

Embryotransfer

OHSS

GnRH agonist

GnRH antagonistP<0.001

P<0.001

P=0.003

P=0.006

Perc

en

t

Ragni et al. Hum Reprod. 2005;20:2421.

Investigator-driven, prospective observational study of women (N=87) at high risk for OHSS, who were treated with a GnRH antagonist protocol following a previous cycle with a GnRH agonist protocol

Endometrial abnormalities in stimulated cycles

Advanced endometrial maturation by 2-4 days

This effect not seen if frozen embryos transferred in natural cycle.

Antagonist vs Long GnRH Agonist: Effects on the Endometrium

No relevant alteration in endometrial thickness

Endometrial dating, estrogen and progesterone receptor expression, and endometrial surface structure were unaffected

Agonist was associated with indications of an arrest in endometrial development

Expression of “window of implantation” genes with antagonist treatment more closely paralleled the pattern observed during a natural cycle compared with agonist

Simon et al. Hum Reprod. 2005;20:3318.

Best Practices for GnRH Antagonist Protocols: Evidence Does Not Support Supplementation of LH Activity

29.531.7

0

5

10

15

20

25

30

35

4035

32.1

0

5

10

15

20

25

30

35

40

Bosch et al1 Meta-analysis2

recFSH

recFSH

recFSH + rLH

hMG

On

goin

g p

reg

nan

cy

rate

(%

)

P=0.61

P=NS

1. Bosch et al. Hum Reprod. 2008;23:2346.2. Baruffi et al. Reprod Biomed Online. 2007;14:14.

On

goin

g p

reg

nan

cy

rate

(%

)

SET = single embryo transfer; DET = double embryo transfer.Adapted from Verberg et al. Hum Reprod. 2008;23:2050.

Lik

eli

hood

of

con

tin

uin

g t

hera

py

(%)

Cycle number

95.9%

93.7%

78.6%

88.3%

75.9%

P=0.034

GnRH antagonist plus SET GnRH agonist plus DET

Continuation of therapy following each cycle

50

60

70

80

90

100

0 1 2 3

GnRH Antagonist and Long GnRH AgonistStrategies Result in ComparableCumulative Pregnancy Rates

0

20

40

60

0 3 6 9 12

Adapted from Heijnen et al. Lancet. 2007;369:743.

GnRH agonist with DETGnRH antagonist with SET

% o

f p

reg

nan

cie

s le

ad

ing

to t

erm

liv

e b

irth

Months since randomization

Singleton term live birth

Proportion of pregnancies leading to cumulativeterm live birth within 12 months after starting IVF

GnRH Antagonist and GnRH Agonist Strategies Result in Shorter Treatment, Better Safety, and Lower Cost

Heijnen et al. Lancet. 2007;369:743.

GnRHAntagonist

(n=444)

GnRHAgonist(n=325) P Value

Days of injections 8.5 25.3 <0.0001

Days of stimulation 8.3 11.5 <0.0001

Total dose of FSH (IU) 1,307 1,832 <0.0001

Incidence of OHSS (%) 1.4 3.7 0.04

Mean total costs €8,333 €10,745 0.006

The low dose protocolIndication - PCOS patientsStart with 37.5u rFSHScan after a weekIf no improvement increase by 37.5 Maintain dose if dominant follicle grows Trigger with agonist

Low dose FSH protocolWeekly increment if no increase in

size

CC- D2- D5 days D6 HMG/FSH 50-150 u /dayLead follicle 13mm, or 6 follicles of 1.2,E2

400ngAdd antagonist 0.25mgm/dayFollicle – 17mmTrigger -1mgm of agonist/HCG 5000iuIUI or ART 36 hrs later Cardone FS2003

Newer forms of isomers.it is unlikely that isoforms of FSH with half-

lives longer than present preparations would have much clinical application except for stimulation of spermatogenesis. For induction of ovulation, a range of products with relatively short half-lives would permit more sensitive manipulation of the therapeutic dose and facilitate achieving mono-ovulation. The current preparations of FSH are likely to continue to dominate clinical use for ovarian stimulation prior to IVF.

Stimulation of follicle development with FSH preparation of differing half-lives (t1/2) to achieve ovulation of a single follicle (Adapted from Baird, 1993).

Baird D T Hum. Reprod. 2001;16:1316-1318

© European Society of Human Reproduction and Embryology

long acting FSH

1 2 3 4 5 6 7 8 9 10 11 12 13 14 ….

FSH-CTP

10000 IE hCG

follicle aspirationafter 36h

GnRH-Antagonist

LF 10 mm LF 14 mm LF 17mm

Ovarian Cortical Strips Transplantation

Dr Muhammad El Hennawy

Ob/gyn specialist 59 Street - Rass el barr –dumyat -

egyptwww.mmhennawy.8m.comMobile 0122503011

Orthotopic Whole Fresh Ovary Microsurgical Transplantation

(A) Depiction of donor oophorectomy.

(B) Microsurgical isolation of donor ovary blood supply.

(C) End-to-end anastomosis of ovarian blood vessel.

(D) Completed anastomosis of ovarian artery and veins.

Why? !Ovarian tissue transplantation is an option for women

who want to protect their fertility and hormones while they undergo treatment for cancer, including chemotherapy and radiotherapy

For women undergoing oophorectomy (in severe or recurrent ovarian disease such as cysts, benign tumours or endometriomas or ovarian pain), accidental bilateral salpingo-oophorectomy for huge uterine fibroids and dense pelvic adhesion--- not only to maintain endocrine functions but also for fertility preservation

Ovarian dysgenesis with missing normal ovarian complement and premature ovarian failure has come in the forefront.

Women in their 20s or 30s could theoretically have an ovary removed and frozen, and then have it reimplanted years later when they are ready to have children as “We are in the middle of an infertility epidemic”

Heterotopic Whole Fresh Ovary Microsurgical TransplantationThe patients' own

ovaries were transplanted to their upper limb to avoid the effect of pelvic radiation as a treatment of Hodgkin lymphoma in one patient and uterine cervical cancer in the other.

How To Prepare Ovarian Cortical StripsUnder general anesthesia One ovary was removed laparoscopically or mini

laparotomy, The whole ovary was transferred to a Petri dishUnder Microscope . dissection with a scalpel and

toothed forceps. It was felt important to prepare a cortical tissue slice

no thicker than ~1.0 mm to facilitate rapid revascularization

While keeping the tissue constantly irrigated with ice-cold medium

Its cortex was prepared in 8 strips of 50x 5 x 1 to 2 mm

DEPENDING ON PATIENT SIZE: from 5 to 15 piecesThe cortex of each ovary was cut into pieces 10 × 10

× 1 mm. ---- 2 or 3 pieces for woman or The cortex of each ovary was cut into pieces 15 ×

5 × 1 mm. ---- 3 or 4 pieces for woman

Transplantation of fresh ovarian cortical pieces under the tunica albuginea

Three pairs of 5-mm transverse incisions were made in the left ovary through the tunica albuginea

With blunt dissection, cavities were formed beneath the cortex for each of the three strips.

Each piece of thawed ovarian tissue (1.5 by 0.5 cm in area and 0.1 to 0.2 cm in thickness) was gently placed in a cavity, and the incisions were closed with 4/0 Vicryl sutures.

In The FutureWomen in their 20s or 30s could

theoretically have an ovary removed and frozen, and then have it re-implanted years later when they are ready to have children as

“We are in the middle of an infertility epidemic”

The newer cinderella

Good follicle and poor endometriun

Individualisation is the key

OOCYTE DEFECTS

FERTILISATION DEFECTS

AND MILES TO GO …..

Last words…..Self-limiting disease of the luteal phaseThe best preventive method is to adapt the

treatment and to closely monitor patients at risk

Garbba Rakshambigai Fertility Centre

ThANK YOU…..

Garbba Rakshambigai Fertility Centre