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Slide 1 - The Women's Clinic

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Slide 1 - The Women's Clinic Powered By Docstoc
					IVM is ready as a treatment
     for PCOS patients

                      Dr. Milton Leong
                                       MDCM DSc (McGill)
                                 Director, IVF Center, HKSH
             Adjunct Professor, OBS-GYN, McGill University



                                                       1
                      PCOS
•   Commonest endocrine disorder in women
•   May be 80% anovulatory infertility?
•   Ovulation induction required
•   Most are clomiphene responsive
•   Cumulative pregnancy rates lower than non-
    PCOS patients



•   Balen 2002 2004
                     PCOS
• Ovulation Induction:

•   Low dose - reduced response
•   Higher dose - over-response
•   Leading to multiple pregnancies
•   Higher risk OHSS
                     PCOS and IVF
• IVF is an effective, may be preferred choice of
  therapy because of the problems associated
  with ovulation induction
• Significantly more oocytes
• Lower fertilization rate

•   Dor et al, Homburg et al Kodama et al
    PCOS and IVF

• Pregnancies were comparable to
  non-PCOS patients
• Increased miscarriage rate
• FSH requirement leads to under or
  over response
• Higher cancellation rate
• Much higher chance of OHSS
   PCOS, OHSS and IVF
• Risk up 5-30 fold (6-30%)
• Estradiol >3000pg/ml
• # Follicles >20
OHSS in PCOS Undergoing IVF

   • Preventive Measures:

   •   Pre-treat with laparoscopic drilling
   •   Use GnRH-ant then GnRH-a to trigger
   •   Metformin (as short as 28 days)
   •   No Transfer, Cryopreservation
   •   Early Aspiration of Follicles - 2 operations


   • Conversion to IVM
   • IVM with and/or without stimulation
                    Progress in IVM
 Edwards 1965 : 1st in vitro matured oocyte
 Veeck 1983 : 1st IVM pregnancy from an ovum derived from a
 stimulated cycle
 Cha et al. 1991 : the first pregnancy from in-vitro matured oocytes derived
  from a caesarean section donor
 Trounson et al. 1994: IVM in women with PCOS
 improvements in culture condition and transfer techniques have
  demonstrated that IVM is an effective treatment for women with PCO or
  PCOS.
 In general, clinical pregnancy and implantation rates for infertile women with
  PCO or PCOS have reached approximately 30-35% and 10-15%,
  respectively, (Chian et al., 2004).

            Advantages of IVM

• No/minimal stimulation:
   less OHSS
   less long term effect
   safety factor – cancer patients
• Flexible start time, no preparation
• Cancer patients
    no theoretical and actual risk (esp br ca)
    can treat anytime
IVM/IVF vs IVF for PCOS




               Child TJ, et al,2002
                    IVM-IVF in POS
210 cycles
1883 oocytes                            56% maturation
                                        83% fertilization
Pregnancy rate                          31% fresh
                                        32% frozen-thawed
50/56 pregnancies                       delivered
Miscarriage                             11%
OHSS                                    0%

A. Fukuda et al, Fertility & Sterility 2008
                                                            12
         Ovulation trigger


LH surge induced by GnRH agonist
achieves identical clinical outcome as
HCG in in vitro maturation, in vitro
fertilization and embryo transfer (IVM-IVF)



                                          13
 GnRHa v.s. HCG in IVF-IVF used in PCOS


300 ųg Buserelin vs 10000 unit HCG
Maturation rate       same       (±50%)
Fertilization rate    same       85%
Pregnancy rate        same       41%
OHSS rate             < 1%

A. Fukuda et al, Fertility and Sterility 2008




                                                14
   Pregnancy Outcome in IVM
• Malformation:
  – Cha, Fertil. Steril. 2005    5,3% major
                                malformation rate


• Later neuromotor development:
  – Soderstrom-Anttila, Hum. Reprod. 2006

  ))) Minor developmental delay at first year
  ))) No Difference in the second year
Known live deliveries from IVM/IVF
    Korea           455
    Taiwan           20
    Colombia          7
    Canada          131
    Finland          52
    Turkey            8
    China            58
    Japan            51
    Vietnam          42
    Hong Kong        18
    Denmark          34
    Italy            56
    UK                8
    Total           930
       McGill IVM results by age group
(own oocytes only – patients with PCO or PCOS)


           Implantation        Clinical       Live birth rate
   Age       rate per      pregnancy rate       per cycle
 (years)     embryo       per cycle started      started
  <35         14.4%            34.8%              20.0%
  35-37       5.4%             20.0%              20.0%
  38-40       5.0%             20.0%              10.0%
 Results of IVM from Shin Kong Wu Ho-Su
    Memorial Hospital, Taipei, Taiwan*
Cycles                               68
Age                                            31.3 ± 4.1
No. of oocytes collected             1,528 (21.9 ± 9.4)
% of oocyte maturation               72.5%
% of fertilization                   75.8%
% of cleavage                        89.4%
Mean of embryos transferred          3.8 ± 0.9
No. of clinical pregnancies (%)      23 (33.8)
% of implantation                    11.3%
% of OHSS                            <1%


  * Data from Dr. Lin & Dr. Hwang (2003)
               IVM/IVF in PCOS

Conclusions:
1.   PCOS is associated with OHSS
2.   OHSS = 80% post EC hospital admissions
3.   IVM/IVF is an established clinical technique
4.   IVM/IVF can reduce incidence of OHSS
5.   IVM/IVF can now be the treatment of choice for PCOS
     in IVF

				
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posted:2/27/2012
language:English
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