1. Limits and Interfaces in Science
HumboldtKolleg
Sao Paulo, Brasil
28.30.
November 2009
RReepprroodduuccttiivvee MMeeddiicciinnee::
aann uuppddaattee
T. Cordes and K. Diedrich
Dept. of Obstetrics & Gynecology
University of Schleswig-Holstein, Campus Lübeck, Germany
4. Milestones in reproductive medicine
• 1960 - ovarian stimulation with clomifene and gonadotrophins
- radioimmunoassay
• 1970 - secretion, synthesis, mechanism of GnRH a. gonadotrophins
- in vitro fertilisation
• 1980 - cryopreservation
• 1990 - recombinant gonadotrophins
- preimplantation genetic diagnosis
- intracytoplasmatic sperm injection (ICSI)
- GnRH-antagonists and gonadotrophins
• 2000 - in vitro maturation of oocytes
- embryonic stemcells
- SET (single embryo transfer)
- vitrification
5. Once upon a time…
07/78 Louise Brown
was born
Birth after reimplantation of a human embryo
Steptoe P.C. / Edwards R.G.
Lancet 2 (1978): 366
6. Number of infertile couples in
Germany:
approx. 15 20%
of all couples
(1.2 – 1.6 Millions)
7. Probability of successfull infertility treatment
after: Dor et al., 1996
cause of infertility pregnancy rate
ovarian 57.7%
tubal 63.3%
male 71.4%
8. Children born after ART until 2006
birth rate
per cycle
worlwide: 3.9 Mio 26%
in Germany : 148.000
21%
(1982-2006)
after in vivo fertilization 24%
9. New Developments in
Reproductive Medicine
• Ovarian stimulation: GnRHantagonists
and long acting FSH
• Elective single embryotransfer (eSET)
• Blastocyst transfer
• Preimplantation genetic diagnosis and screening
• Invitromaturation
• Cryopreservation and vitrification
10. History of ovarian stimulation
• 1970 Clomifen
hMG
• 1980 GnRH-agonist / hMG
• 1990 recFSH
GnRH-antagonist / hMG or recFSH
• 2000 long acting FSH
11. Efficiancy of ovarian
stimulation with hMG
endogeneous LH surge (progesterone): 22%
(Stanger et al. 1985)
oocyte quality
embryo quality
pregnancy rate
incidence after down regulation: <2%
12.
13. 8
6
4
2
0
8
6
4
2
0
LHRH-agonist: daily injection/ depot/ nasal spray
d 6
d -14
Ampoules
Gonadotropins
Menses
Ampoules HMG
Menses
Cetrorelix
HCG
OPU
HCG
OPU
ET
ET
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
day of cycle
-16 -14 -12 -10 -8 -6 -4 -2 0 2 4 6 8 10 12 14 16
17 day of cycle
„long protocol“
„Lübeck
protocol“
GnRHagonist
and antagonist protocol
15. Does the probability of live birth after ovarian
stimulation and IVF depend on the type of GnRH-analogue
used?
A systematic review and meta-analysis
G Griesinger, J Collins, B Tarlatzis,
P Devroey, K Diedrich, EM Kolibianakis
17. Hospital admission due to OHSS
Citation Year Rate1 Rate2 PValue 0,01 0,1 1 10 100
Effect Lower Upper
Albano 2000 ,00 ,01 ,20 ,16 ,01 3,91
Badrawi 2005 ,04 ,04 1,00 1,00 ,15 6,82
Bahceci 2005 ,04 ,07 ,49 ,62 ,15 2,49
European 2000 ,01 ,02 ,07 ,33 ,10 1,17
Lee 2005 ,07 ,10 ,72 ,73 ,13 4,04
Middle East 2001 ,02 ,05 ,07 ,34 ,10 1,17
North American 2001 ,01 ,02 ,76 ,76 ,13 4,46
Olivennes 2000 ,02 ,05 ,25 ,34 ,05 2,35
RandomCombined (8) ,01 ,47 ,27 ,84
Favor agonists Favor antagonists
RR : 0.47
~ 2 times less risk to be admitted due to OHSS with GnRH antagonists
18. Advantages of GnRH-antagonists
- fits into the normal cycle
(„the patients like it“)
- less side effects in comparison to the long protocol:
1. Ø cysts
2. Ø hormonal withdrawl
3. less OHSS
4. simple
- no significant difference in the probability
of live birth between GnRH-agonists and
antagonists
19. long acting FSH
FSH-CTP
10000
IE hCG
follicle aspiration
after 36h
1 2 3 4 5 6 7 8 9 10 11 12 13 14 ….
GnRH-Antagonist
LF 10 mm LF 14 mm LF 17mm
20. New Developments in
Reproductive Medicine
• Ovarian stimulation: GnRH-antagonists and long acting FSH
• Elective single embryotransfer (eSET)
• Blastocyst transfer
• Preimplantation genetic diagnosis and screening
• In-vitro-maturation
• Cryopreservation and vitrification
21. Children after ART: 1997-2002
DIR 2001
IVF ICSI Total %
Singleton 11455 12096 23551 59.83
Twin 6782 6553 13335 33.87
Triplet 1228 1221 2449 6.22
Quadruplet 23 8 31 0.08
Total 19488 19878 39366 100
22.
23. Problems of multiple pregnancies
• pregnancy related diseases
• prematurity
• increase of neonatal morbidity and mortality
• costs
24. Aims
1. To avoid multiple pregnancies
2. Improve the pregnancy and life birth rate
Solution: Transfer of one selected embryo
26. Pregnancy rate after
elective single embryo transfer (eSET) and
elective double embryo transfer (eDET)
eSET = 40.3% pregnancy rate
1% gemini
eDET = 44% pregnancy rate
32% gemini
Gerris, 2005
ESHRE
27. Prison sentence up to three
years or financial penalty for
§ 1, Abs. 1, Nr. 3
„a person transfering more than
3 embryos to the womb in the
course of one treatment cycle“
§ 1, Abs. 1, Nr. 5
„a person fertilizing more oocytes
than he or she intends to tranfer in
the course of one treatment cycle“
28. Germany vs. Sweden
No. of embryos / ET
after IVF and ICSI, 2004
Deutschland Schweden
1 embryo 11.6% 67.4%
2 embryos 61.3% 32.5%
3 embryos 27.1% 0.1%
Andersen et al., 2008
29. Germany vs. Sweden:
Multiple pregnancies after ART
born children (IVF) / ET 18.3% 26.4%
gemini / ET 20.7% 5.6%
triplets / ET 1.1% 0.0%
DIR 2004; Andersen et al., 2008
30. New Developments in
Reproductive Medicine
• Ovarian stimulation: GnRH-antagonists and long acting FSH
• Elective single embryotransfer (eSET)
• Blastocyst transfer
• Preimplantation genetic diagnosis and screening
• In-vitro-maturation
• Cryopreservation and vitrification
33. Preimplantation Genetic Diagnosis
Indication: High risk of genetic diseases.
Preimplantation Genetic Screening (PGS)
Aneuploidie-Screening improves the
pregnancy rate and abortion rate especially in
older women (??)
35. Präimplantationsscreening
ASRM Committee Report, 2008
A careful review of the published studies of this
technique led the ASRM Practice Committee to conclude
that the available evidence does not support the use of
PGS to improve live-birth rates in patients with
advanced maternal age, previous implantation failure,
recurrent pregnancy loss, or to reduce miscarriage rate in
patients with recurrent pregnancy loss related to
aneuploidy at this time.
36. New Developments in
Reproductive Medicine
• Ovarian stimulation: GnRH-antagonists and long acting FSH
• Elective single embryotransfer (eSET)
• Blastocyst transfer
• Preimplantation genetic diagnosis and screening
• In-vitro-maturation
• Cryopreservation and vitrification
37. First oocyte maturation in vitro
The Lancet 1965
„Oocytes from antral follicles can
finalize their meiotic maturation in
vitro in 24 – 48 hours“
R.G. Edwards et al.
Edwards RG et al. 1965
38. Physiological basics of IVM
Early oocyte retrieval from antral follicles before
selection and atresia . . .
day 3 day 8 - 12
d>10mm
39. Development of IVM
1983 Veeck First birth after IVM
1991 Cha IVM on immature oocyte extracted by
using ovarian biopsy during a
cesarean section resulted in healthy twins
2000 Cha birth of 20 healthy children after IVM
2003 Mikkelsen birth of 33 healthy children after IVM
today >300 children after IVM
40. Therapeutic indications for IVM
• PCOS
• high responder with a risk for OHSS
• normo-cyclic patients
• cryopreservation of oocytes (oncology)
• low responder
• implantation failure
Mikkelsen et al. 2003, Smitz 2005, von Otte 2005
41. Tag 1 2 3 4 5 6 7 8 9 10 ….
IVM
oocyte
maturation
(24 h)
first
Examination:
basic
ultrasound and
hormone level
Embryo
transfer
2-3 days after
ovum aspiration
embryo
culture
(2- 3 days)
Menses
♂
Male:
sperms
Fertilization
via ICSI
4 days
of low dose hMG
(„priming“ with
75IE hMG/day)
Exam.
2,3, …
ultrasound
and
hormone
level
primordial follicle
≥ 12mm
and E ≥7mm
10.000 IE hCG
36h later
aspiration of small
antral follicles
Estradot 100
Crinone 8%
Treatment protocol
42. In vitro maturation of oocytes
number of patients 140
Metaphase II 57%
2 pronuclei after
in vitro maturation and ICSI 47%
pregnancies 30
v. Otte 2007
43. New Developments in
Reproductive Medicine
• Ovarian stimulation: GnRH-antagonists and long acting FSH
• Elective single embryotransfer (eSET)
• Blastocyst transfer
• Preimplantation genetic diagnosis and screening
• In-vitro-maturation
• Cryopreservation and vitrification
45. --55
377°°CC
TTeemmpp DDeeggrreeeess CC
--880
--119966
V I T R I F I C A T I O N Slow freezing
RRoooomm
tteemmppeerraattuurree
(equilibrated)
0.3 – 0.5° C/min
TTeemmppss ((mmiinn))
Vitrification vs slow cooling
total dehydratation
10 20 30
H2O
> 25000°C/min
Storage
Storage
H2O
Storage
weak dehydratation
Weak dehydratation
--355
46. Slow cooling
(Whittingham et al., Science 1972,
Willmut et al., Life Science 1972)
- 0.3°C/min
Vitrification
(Rall and Fahy 1985)
2 sec.
- 50.000°C/min
48. Clin. pregnancies / ET
after cryo transfer
(1996-2004)
Cryo transfer 67,257
Clin. pregnancy / ET 15.5 %
Abortion rate after cryo transfer 21.64 %
German IVF Index 2004
51. Future of Reproductive Medicine
• new embryo protection law (european?)
• improvement of pregnancy rate by the elective single embryo
transfer (morphological criteria)
• avoid multiple pregnancies
• vitrification
• in vitro maturation
• Fertility preservation for women with cancer
• aim of infertility treatment: simple, safe, comfortable,
successful and cheap
Dear Mr. Chairmen, Colleagues, Ladies and Gentleman. It is a great pleasure having the opportunity to present the results of our systematic review at this years ESHRE meeting. We asked a question, which was: Does the probability of live birth depend on the type of GnRH-analogue used? Now, want to present to you the way we strived to answer this question and also the answer that we suggest can be derived from the available evidence.
Frisch punktierte, reife Eizelle in Follikelflüsigkeit, umgeben von einer aufgelockerten Granulosazellmasse, dem Cumulus oophorus, Größe der Oozyte??
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