Dr. Lister de Lima Salgueiro

Focus Points

1. Ovarian Modern Physiology

2. Ovarian Reserve Evaluation

3. Basal Testosterone

4. Ovulation induction: Long Protocol

5. Embryo Transfer

6. Luteal Phase Support

7. OHSS management

8. Results

Modern Physiology

• Modern Physiology of the menstrual cycle

• Recruitment (window)

• Recruitment in induced cycles

• Polimorfism of FSH receptors

• Ovarian Response

Modern Physiology of Ovarian Cycle

Simple ovulation

Ovulation

Ovulation

Ovulation

Multiple ovulation – More follicles

Multiple Ovulation – Larger Window

(Two Cohorts)

Polymorphism of FSH

Receptors

FSHr Receptors – cromossome 2

Inactivating Mutations

○ Hipotalamic Amenorrea

○ Primary: homozygous

○ Secondary: heterozigous

○ Premature Ovarian failure

Activating Mutations

○ Spontaneous OHSS

○ Increase sensibility to FSH/HCG/TSH

○ Normal Espermatogênesis in the absense ofFSH

Effect of FSHr in natural

cycle

P4

SER

ASN

FSH

M

E2 < in cases with FSH

Ovarian Response ASN (Asparginine)

< number of follicles

Define cycle lenght

Decrease of negative E2 feedback

Recruitment increase

Cycle lenght increase

Higher FSH Treshold

SER (Serine) > follicle number

At least less 30 cycles

OBS: PCR determination

Polimorfism of FSH Receptors

• The stimulation response depends of FSH receptors performance

• Homozigose

• Asn-Asn – Poor response (homozigous)

• Asn-Ser – Normal (heterozigous)

• Ser-Asn – Normal (heterozigous)

• Ser-Ser – Hi responder (homozigous)

Basic Concepts

• 50% From those with poor response

wil have porro response at the first cycle

• 50% increase the response in the second

cycle with the same stimulation protocol

• 70% will have better performance in the second cycle

Evaluation of Ovarian Reserve

• FSH basal

• Antral Follicle Count (AFC)

• AMH

• Basal Testosterone

Ovarian Reserve Evaluation: Basal FSH

• When measure? : Cycle Day 3

• Always measure estradiol to avoid false negatives

• Can vary from cycle to cycle

• One alteraded value- poor prognosis

• Elevated FSH (>15)- Response almost never change

Antral Follicle Count - AFC

Poor response prognosis

AMH

Produced by Granulosa céls

From follicle primary to antral

Low or no dependence to FSH

Best ovarian age marker

< AMH can have precocious menopause

AMH not change with sequencial cycles

AMH x Age

20 30 40 50

AMH

AGE

AMH Results

IVF Survey 2010

Basal Testosterone

Cycle Preparing

• Estrógens

• Andrógens

• Testosterone

• DHEA

• Aromatase Inhibitors

• Dexametasone

• LH

• GH

• ACO

• Crash IVF

Luteal Phase Supression

Estradiol:

D20 D2

E2 - 4 mg/day Gonadotrophins

Short Protocol

• E2 supress FSH

• Decresase last cycle stimulation

Androgens and Follicular

Stimulation

Synergic action of Testosterone with FSH

Prolonged Ovulation Stimulation

Association with small follicles

Can predict the ovarian response

Suplementation

Testosterone

Testogen

○ Poor responder

○ During 15-20 days

○ Without significative disfunction

○ No effect in: Number of basal follicles

Mature follicles

Oocytes

Embriyos

Pregnancy rate

DHEA Suplementation

DHEA – 75mg/day by 4 months

DHEA Suplementation

DHEA – 75mg/day for 4 months

Benefit effect on eggs and embryos: Improve pregnancy chances

Decrease abortment rate

Improve integrity of cromossomes

Improve endometrial conditions

Reduce the aneuplydy incidence

Used by 1/3 of the clinics

Aneuplidy Origens:

- Eggs 90%

- Espermatozoa 9%

- Embryos 2%

Aromatase Inhibitors

Block transition T-DHT increasing

Testosterone

Increase of:

Antral follicles

Oocytes

Implantation rate

3 to 7 days during the cycle

Dexametasona

LH

Before the cycle

300 IU/day

Bloqueia com Triptorelina Depot

200 UI FSH dia

HCG com fol > 12 mm

Reduz risco de SHO

Dim. número de folículos pequenos

GH Hormônio do

Crescimento

• Cochrane Review

• Without impact on stimulation parameters:

• E2 Peak

• Stimulation Lenght

• Gonadotrophins Requirements

• Only 3 studies reported births

Oral Contraceptives

• Previous use to the cycle

• At least 15 days

• Bleeding occurs between 48 and 72h

• Stimulation must start between days 1 and 5

• Endocrinology alteration

• Follicle growth rate alterated

• Increase in FSH dose

• Increase in stimulation lenght

Luteal Phase Supression

GnRHant: Crash

D23 ou 25 D2

Gonadotrophins

Short protocol

• GnRHant supress previous cycle stimulation

• Luteólisys

3.0 g GnRHant

CRASH Protocol

• Less than 35 years

• Poor responder

• Basal FSH normal

• Luteólisys with GnRHant

• Short protocol

Ovulation Induction

• LH

• Less is More

• Cohort

• Choosing agonists/antagonists

LH During the cycle

Indications:

> 35 years

Suboptimal response to FSH

How Much LH?

○ 75 UI

○ LH ceiling = atresia (> 375 UI)

○ Filicori used 200 UI without problems

Use in Hipogonadotrófic/Hipogonadism

LH Window: Follicular

Phase

Agonist

Antagonist

S0 S 5-8 S - HCG

LH

LH alto no day8 – aum abortamento

Triptorelina

Leuprolida

Buserelina

Nafarelina

Incremento

na potência

do antagonista

Potência

confunde

Bosch 2008: > 35 anos

• Com e sem LH

• Taxa de gravidez igual

• Tx de implantação igual

• Taxa de abortamento igual

LH use:

• Earlier:

• Increase Androgen synthesis

• Stimulates the Recruitment

• Late

• Physiological Manutention

• Increase of E2 synthesis

• Control of the follicular growth

LH = More Euploidy

Weghofer 2008

OVULATION INDUCTION

GnRH Agonist

Individualised Dose FSH rec®1

Lupron® 1.0 mg/day/for 14 days 0.5 or 1.0mg / day

150/225 IU

per day

day1

of FSH rec®

Day7

of FSH rec® HCG rec®

day21

Down regulation

Long Protocol

Why only two Ultrassound

exams?

• First Exam day 7:

• Follicle count

• Follicle Measurement

• Endometrium classification

• Endometrium measure

Why only two Ultrassound

exams?

• Second Exam day 10 or 11:

• Follicle count

• Follicle Measurement (Growth rate)

• Endometrium classification

• Endometrium measure

• Calculate the HCG day

Follicular Cohort

• Same cohort per patient

• Dose independent

• Less is more

• Actual recommendations:

• < 30 years 150 IU/day

• > 30 years 225 IU/day

LESS IS MORE• Lower Dose of FSHr:

• Smaller Cohort

• More Syncrony

• Higher number of MII

• Less incidence of Aneuploidy

• Higher Fertilization Rate

• Higher Pregnancy Rate

Increased gonadotrophin stimulation does not improve IVF

outcomes in patients with predicted poor ovarian reserve

Dharmawijaya N Lekamge & Michelle Lane &

Robert B Gilchrist & Kelton P Tremellen

Less Than 30 years

• Low Responders: Upgrade to 30/37 years protocol

• Normal Responders:

• Gonal-F 150 IU for seven days

• Step-down to 75 IU

• Keep untill the day before HcG

• High Responders:

• Gonal-F 150 IU for 3 days

• Step-down to 75 IU

• Keep untill the day before HcG

From 30 to 37 years

• Low Responders: Upgrade to >37 years protocol

• Normal Responders:

• Gonal-F 225 IU for seven days

• Step-down to 150 IU (one day)

• Step-down to 75 IU

• Keep untill the day before HcG

• High Responders:

• Gonal-F 225 IU for 3 days

• Step-down to 150 IU (day 4)

• Step-down to 75 IU

• Keep untill the day before HcG

More Than 37 years

• Low Responders: Do not Upgrade the dose

• Normal Responders:

• Gonal-F 300 IU for seven days

• Step-down to 225 IU (one day)

• Step-down to 150 IU (one day)

• Step-down to 75 IU

• Keep untill the day before HcG

• High Responders:

• Gonal-F 300 IU for 3 days

• Step-down to 225 IU (day 4)

• Step-down to 150 IU (day 5)

• Step-down to 75 IU

• Keep untill the day before HcG

Why use Step-down

Protocol?

• Respect the Physiology

• Avoid the second cohort recruitment

• Prevent Assincrony

• More Mature follicles

Why choose Agonist

Protocol?• Better response

• Possibility to use almost fix protocol

• Less FSHr dose

• Less Assincrony

• Less Aneuploidy

• Higher number of mature eggs (MII)

• Higher Fertilization Rate

• Less incidence of moderate OHSS (2%)

• Higher Pregancy Rate

Almost Fixed Protocol ?

START

Gonadotrop

hins

US

Day 7

US Day

10 or

11

hCG Ovum

Pickup

Transfer

Day 3

Transfer

Day 5

Saturday Friday Monday Tuesday Thursday Sunday Tuesday

Wednesday Friday Monday Wednesday

Wednesday Tuesday Friday Saturday Monday Thursday Saturday

Tuesday Friday Monday Wednesday

Never :ovum pick-ups on Saturdays or Sundays

Sometimes: Embryo Transfer on weekends

Why use Agonists ?

Huirne et al. 2007;22:2805-2813

GnRH agonist x GnRH antagonista: Follicle Syncrony

Agonist Antagonist

Implantation Window

Progesterone on hCG Day

• Measure P4 on hCG day

• > 1,5 cycle lost (?)

• Antagonist 4/7/before hCG

TOTAL

P4 Level Number BhCG + % Ongoing % Abortion % Ong Pregn Rate

P4 <1,00 303 158 52,1% 109 69,0% 49 29,0% 36,0%

P4 1,0 a 2,0 310 131 42,2% 84 64,1% 47 25,9% 27,1%

P4 2,0 a 3,0 31 9 29,0% 7 77,7% 2 28,5% 22,5%

P4 3,0 a 4,0 7 2 28,5% 1 50,0% 1 50,0% 14,3%

P4 > 4,0 14 2 14,3% 1 50,0% 1 50,0% 7,1%

LESS THAN 35 YEARS

P4 Level Number BhCG + % Ongoing % Abortion % Ong Pregn Rate

P4 <1,00 173 111 64,1% 14 12,6%

P4 1,0 a 2,0 195 87 44,6% 15 17,2%

P4 2,0 a 3,0 20 5 25,0% 0 0,0%

P4 3,0 a 4,0 5 2 40,0% 0 0,0%

P4 > 4,0 9 1 11,1% 0 0,0%

Progesterone limitation

Embryo Transfer – Best Day

Aspirin

• Low dose: Aspirin prevent 100

• Increase:

• Ovarian Response

• Ovarian and Uterine blood influx

• Implantation Rate

• Pregnancy Rate (15%)

• Risk of Haemorragic accidents

OHSS (Old)

• Coasting: maximun 2 days

• Renin/angiotensin Blockers:

• Dostinex 1 pill/VO/day/7 days

• Losartana 10 mg 1 pill/VO/day/7 days

+

• Enalapril 8 mg ½ pill/VO/2x day/ 7 days

• Quinagolide 100 mg 1 cp/VO/day/ 7 days

OHSS (New)

• Normal Ovum Pickup

• Presence of Symptoms:

• Ovarian enlargement

• Slow Intestinal transit.

• Ascitis

• Frezze All (Eggs or Embryos)

• Aplication of 4 Cetrotide Syringes (At the same time)

• Regression of the symptoms in 4 days

• Transfer in the next cycle

• OHSS incidence : 2% of the cycles

Fértilis Clinic Results 2012/2014:

Number %

Cycles 585

Oocytes 4161 7,1 (p/c)

MII 3453 83,0%

Fertilized 2901 84,1%

Clived 2750 94,8%

Transfered 1307 2,2

Pregnancy (overall) 289 49,3%

OHSS 12 3,41%

Fértilis Clinic Results Per

Age:

Age Number of

Cases

% Positive

<35 259 60,5%

36-40 111 50,5%

>41 54 39,0%

Why should I change to Antagonists???

END

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