WORLD IVM EXPERIENCE Milton K. H. Leong, M.D. IVF Centre Hong Kong Sanatorium & Hospital, China
Jan 15, 2016
WORLD IVM EXPERIENCE
Milton K. H. Leong, M.D.
IVF Centre
Hong Kong Sanatorium & Hospital, China
LEARNING OBJECTIVES
At the conclusion of this presentation, participants should be able to:
1. Describe the indications IVM
2. Outline the various IVM approaches undertaken currently.
3. Evaluate the IVM outcomes with regard to the treatment success rates and the babies born as a result of IVM treatment.
DISCLOSURE
Milton K. H. Leong, MD
None
Development of IVM
• It was first demonstrated in 1935 that the immature oocytes have the ability to resume meiosis spontaneously when removed from the follicle.
–Pincus G, Enzmann EV. J. Exp. Med. 62, 665-675 (1935)
• Edwards showed that in-vitro matured human oocytes could be fertilized.
–Edwards RG, Bavister BD, Steptoe PC. Nature. 221(5181), 632-5 (1969).
• the immature human oocytes retrieved during gynecologic surgery in an oocyte donation program resulted in the first IVM pregnancy in 1991.
–Cha et al., Fertil Steril 55; 109-13 (1991).
• 1994-first IVM pregnancy with a patient’s own oocytes.
– Trounson A, Wood C, Kausche A. Fertil Steril 62; 353-62 (1994)
Development of the follicleStage Follicle size (mm)
Primordial 0.03 - 0.04Primary 0.05 - 0.06Secondary 0.07 - 0.11Preantral 0.12 - 0.20Early antral (*) 0.21 - 0.40Antral (* +) 0.41 - 16.00Preovulatory (+) 16.10 - 20.00
+ IVF * IVM
Gougeon, Hum Reprod 1986;1:81-7
Target patient group
• Women with high AFC;– PCOS– PCO with regular cycles
• The most significant factor which determines the success of IVM treatment is the AFC of the woman
(Tan, 2002. Am. J. Obstet. Gynecol. 186; 684-9)
Patient selection for IVM
Suikkari 2007; Best Practice & Res Clin Obstet Gynecol 21; 145-155
promising outcomes are also reported in “regular cycling” women
Suikkari 2007; Best Practice & Res Clin Obstet Gynecol 21; 145-155
Better prognosis if AF basale count > 7Better prognosis if AF basale count > 7
Common Indications for IVM
• failure after > 6 cycles of ovulation induction
• women having IVF with high AFC
• repeated poor embryo quality in previous IVF cycles for no obvious reason
• repeated poor responders to ovarian stimulation
however
• low implantation rates when compared to conventional stimulated cycles.
– asynchrony in the cytoplasmic and nuclear maturation of the oocyte
– asynchrony in the endometrium– culture conditions
Various approaches to improve implantation rates in IVM
• Gonadotropin priming – None– hCG– FSH / FSH+hCG
• Metformin• IVF / ICSI
• Culture conditions
Clinical Laboratory
HCG Priming
• Theoretically;
– Promote invitro maturation– Improve pregnancy rates
IVM following hCG priming
• Cycles of IVM 25• Age (yrs) 35.4 4.7• Oocytes retrieved 10.3 5.4• Maturation rate (%) 84• Fertilization rate (%) 87• Cleavage rate (%) 95• Embryos transferred 2.9 0.6• Clinical pregnancies - no (%) 10 (40)
Chian et al
New Engl J Med 1999; 341:1624-6
0
10
20
30
40
50
60
70
80
90
0 12 24 36 48
+ HCG
- HCG
hours of culture
% o
f m
etap
has
e II
*p < 0.05
Chian et alHum Reprod 2000; 165-170
Response to LH in granulosa cells from follicles < 8 mm from ovulatory women (with normal ovaries or PCO compared to anovulatory women with PCO)
Fold increase in steroid accumulation in response to LH
above control
Patients Estradiol Progesterone
Ovulatory (normal and ovPCO) 1.0 (5.0 - 3.9);
(n = 46)a
1.0 (0.3 - 2.5);
(n = 42)c
Anovulatory (anovPCO) 1.4 (0.7 - 25.4);
(n = 17)b
1.3 (0.3 - 7.0);
(n = 20)d
a vs b, P<0.0003c vs d, P<0.03
Willis et al., Journal of Clinical Endocrinology and Metabolism 1998; 83:3984-91
Duration between HCG administration and oocyte retrieval
• When the durations of 35 hours vs. 38 hours between hCG administration and the oocyte retrieval were compared, the 38 h group yielded significantly higher number of mature oocytes.
• In-vitro maturation rate after 24 h in the culture was significantly higher, and the clinical pregnancy rate in the 38 h group was higher compared to the 35 h group in the unstimulated cycles, 40.9% vs. 25%.
Son et al. Fertil Steril 88(Suppl. 1), S24-S25 (2007).
Clinical outcome in hCG-primed IVM cycles with (Group 1) and without (Group 2) MII-stage oocytes on the day of retrieval
Groups Group 1 (n=48) Group 2 (n=46) P
No. of oocytes collected (mean + SEM)
922 (19.2 + 8.4) 854 (18.6 + 9.9) NS
No. of MII-stage oocytes collected (%)
135 (14.6) 0
No. of oocytes cultured 787 854 NS
No. of oocytes matured in vitro (%) 500 (63.5) 535 (62.6) NS
Total no. of oocytes matured (%) 635 (68.8) 535 (62.6) NS
No. of oocytes fertilized (%) 456 (71.8) 419 (78.3) NS
No. of oocytes cleaved (%) 396 (86.8) 377 (90.0) NS
No. of oocytes transferred (mean) 178 (3.7) 173 (3.8) NS
No. of pregnancies (%) 23 (47.9) 13 (28.3) <0.05
Son WY et al. RBM Online. (2008), in press
Hormonal Priming
Regular cycling PCOS
• BeneficialBeneficial•Wynn 1998Wynn 1998
• No differenceNo difference•Trounson 1998Trounson 1998•Suikkari 2000Suikkari 2000•Mikkelsen 2005Mikkelsen 2005
• BeneficialBeneficial•Mikkelsen 2001Mikkelsen 2001
• No differenceNo difference•Lin 2003Lin 2003•Chian 2000Chian 2000
FSH Priming
• Results are conflicting
• Potential benefits:– Larger ovarian size– Easier retrieval– Higher E2 levels– More maturational competence
May May improve endometriumimprove endometrium
Overview of IVM treatment cycle
• Withdrawal bleed• U/S scan day 2-4 to identify if PCO and
measure AFC• Repeat u/s scan on day of hCG to measure
endometrial thickness• s/c hCG 10,000 IU when ET 6-8 mm, largest
follicle 10-12 mm and oocyte retrieval 38 hours later
Transvaginal U/S-guided oocyte retrieval
• vaginal vault cleansed with sterile water• i.v. sedation sedation with fentanyl and L.A. • 19 G single single-lumen needle • reduced aspiration pressure (7.5 kPa)• multiple punctures• 10 ml culture tubes with 2ml warm 0.9% saline
with 2 IU heparin
In-vitro maturation of oocytes
• GV oocytes cultured in IVM medium supplemented with 75mIU/ml FSH + LH for 24 - 48 hrs, checked every 12 hours all MII oocytes undergo ICSI
• ET day 2 or 3 following ICSI
• Patients receive estradiol-17ß (micronized) immediately following OR and progesteron following ICSI
Endometrial Priming
Endometrium is Endometrium is
exposed to lowerexposed to lower
E2 levelsE2 levels
Dyssynchrony between phase Dyssynchrony between phase of endometrium – matured of endometrium – matured
oocyteoocyte
Endometrial preparation is necessaryEndometrial preparation is necessary
Endometrial preparation
Endometrial thickness on day of oocyte retrieval
<6 mm 10 - 12 mg estradiol-17ß (micronized)
6 - 8 mm 8 - 10 mg estradiol-17ß (micronized)
>8 mm 6 mg estradiol-17ß (micronized)
Progesterone support (50 mg I/M or 200mg tid, pv) started following ICSI
Timing of Oocyte Retrieval
Early atreticEarly atreticfolliclesfollicles
Dominant follicleDominant follicle
Still competent toStill competent toEmbryonic developmentEmbryonic development
Can be used in IVMCan be used in IVM
But; TIMING ?But; TIMING ?
Timing of Oocyte Collection
• Russell et al. (1999)
When the leading follicle > 13 mm
• Less oocytesLess oocytes
• Less fertilizLess fertilizationation
• Fewer embryosFewer embryos
Timing of Oocyte Collection
• Cobo et al. (1999)
When the leading follicle < 10 mm
Higher blastocyst formationHigher blastocyst formation
Metformin in IVM
• 56 women, 70 cycles • Metformin, 500 mg bid for 12 weeks before the IVM
treatment • HMG for 5 days and hCG 10,000 IU, 36 h prior to OPU• number of immature oocytes, oocyte maturation,
fertilization and cleavage rates in were comparable to the control group
• significantly higher implantation and clinical pregnancy rates were obtained in the metformin-treated group (15.3% and 38.2% respectively) compared to the controls (6.2% and 16.7%)
Wei Z et al. Fertil Steril 2007 Nov 15
IVM outcomes
Authors (year) No. of cycles
Indication No. of ET cycles
at cleavage stage
GnPriming
MaturationRate (%)
FertilizationRate (%)
Implantation
Rate (%)
Pregnancy Rate/ET
(%)
Miscarriage Rate (%)
Chian et al (1999) 25 PCOS 25 HCG 84 87 32 40 20
Cha et al (2000) 94 PCOS 85 None 75.1 67.9 6.9 27.1 26.1
Chian et al (2000) 1113
PCOS 1113
NoneHCG
69.184.3
83.990.7
24.816.6
27.338.5
040
Mikkelsen and Lindenberg (2001)
1224
PCOS 921
NoneFSH
44.059.0
69.070.0
021.6
033.3
57.1
Child et al (2002) 107 PCO/PCOS
107 HCG 76.0 78.0 9.5 26.2 26.1
Lin et al (2003) 3533
PCOS 3533
FSH+HCGHCG
76.571.9
75.869.5
9.511.3
31.436.4
13.0
Chian (2004) 254 PCO/PCOS
NA HCG 78.8 69.2 11.1 24.0 NA
Soderstrom-Anttila et al (2005)
PCO: 13 7
PCOS: 18 10
PCO: 13 7
PCOS: 18 10
9 (IVF)5 (ICSI)17 (IVF) 9 (ICSI)
None 60.649.254.353.2
35.072.482.570.0
13.30
34.512.5
22.20
52.922.2
0-
33.350.0
Cha et al (2005) 203 PCOS 187 None NA NA 5.5 21.9 36.8
Torre et al (2007) 138 PCOS NA HCG 61.7 62 10.9 24.5* 42.3
Son et al (2007) 415106
PCO/PCOS
415106
(blastocyst)
HCGHCG
74.078.2
80.180.5
9.726.8
28.451.9
NA21.8
Outcome of IVM cycles from literature in women with PCO/PCOS.
Outcome of IVM cycles from the literature in women with normal ovaries and regular cycles.
Authors (year)
No. of cycles No. of ET cycles
at cleavage
stage
GnPriming
Mean no. of oocytes retrieved
Maturation
Rate (%)
FertilizationRate (%)
Implantation
Rate (%)
CPR/ET (%)
M/CRate (%)
Child et al. (2001)
56 (normal)53 (PCO)
68 (PCOS)
505267
HCGHCGHCG
5.1 ± 3.710 ± 5.111.3 ± 9
79.575.9*
67.771.6*
1.58.99.6
423.129.9
502550
Mikkelsen et al. (2001)
132 83 None 3.9 60.1 72.9 NA 18 NA
Soderstrom-Anttila et al. (2005)
92 (IVF)100 (ICSI)
58 (IVF)86 (ICSI)
None 6.3 ± 3.46.5 ± 3.6
66.954.5
35.967.1
22.615
3121
33.316.7
* PCO and PCOS groups pooled together.
IVM for other indications
IVM oocyte donation
• 12 oocyte donors (29.7 yrs; AFC 29.7) • oocyte retrieval days 9-18 of unstimulated cycle• mean of 12.8 GV oocytes retrieved• 8.67 mature oocytes and 5.9 fertilized oocytes• 3.9 embryos transferred• implantation rate 19.1%; 6/12 clinical pregnancy
– 4 delivered Holzer et al
Fertil Steril 2007; 88: 62-67
IVM +/- natural cycle IVF and PGD
• 35 yr old with RM failed 2 IUI and 2 IVF • IVM offered because of PCO; 1 M II and 14 GV oocytes;
ICSI performed• 8 embryos, 6 biopsied, 1 embryo from MII oocyte and 1
from GV oocyte chromosomally normal for 6 autosomes and X and Y chromosome
• 2 ET – one blastocyst from MII oocyte and one morula from GV oocyte
• ß-hCG 399 IU 14 days after ET and livebirth in May 2005
Ao et al
Fertil Steril 2006;85:1510-12
IVM as a Rescue
• Some cycles are cancelled due to– Risk of OHSS– Poor pesponse
Can IVM be a Can IVM be a rescuerescue ? ?
these oocytes can be matured in-vitrothese oocytes can be matured in-vitro
IVM as a rescue
Risk of OHSS
Immature oocyte retriavalImmature oocyte retriaval ++ IVMIVM
47 % CLINICAL PREGNANCY47 % CLINICAL PREGNANCY
No OHSSNo OHSSLim Lim et al. et al. Fertil Steril 2002Fertil Steril 2002
10,000 IU HCG10,000 IU HCG
Leading follicle = 12-14 mmLeading follicle = 12-14 mm
IVM as a rescue
• In POOR RESPONSE = E2 < 1000 pg/ml
< 4 mature oocytes
Poor responders no HCG Poor responders no HCG
Immature oocyte retrieval + IVMImmature oocyte retrieval + IVM
37,5 % Pregnancy rate37,5 % Pregnancy rate
Liu Liu et al. et al. Fertil Steril 2003Fertil Steril 2003
IVM for Fertility Preservation
Fertility preservation for young women
• Best option; embryo cryopreservation, after ovarian stimulation followed by oocyte retrieval and fertilization of oocytes by sperm; IVF or ICSI
• Probably second best;
oocyte cryopreservation after ovarian stimulation followed by oocyte retrieval
Ovarian stimulation is not suitable for certain cancer patients; no sufficient time and/or ovarian stimulation contraindicated
Solution ?
Trial: Retrieval of immature oocytes from unstimulated ovaries, and maturation in-vitro followed by cryopreservation of oocytes by vitrification
Viability and pregnancy outcome of vitrified IVM oocytes
No. of patients 20
Mean age 30.8 + 0.9
No. of mature oocytes retrieved 6
No. of immature oocytes retrieved 290
Mean oocyte maturation rate 67.3 + 4.9
No. of oocytes vitrified and thawed 215
No. of oocytes survived (mean % + SEM; range) 148 (67.5 + 5.8; range 23.5 -100.0)
No. of oocytes fertilized (mean % + SEM) 96 (64.2 + 4.5)
No. of embryos transferred (median; range) 64 (4; range 1 - 6)
No. of implantations (mean % + SEM) 4 (9.6 + 5.4)
No. of pregnancies (%) 4 (20.0)
No. of clinical pregnancies (%) 4 (20.0)
No. of ongoing pregnancies (%) 0 (0)
No. of live births (%) 4 (20.0)
Mean birth weight (grams) 3486
Chian et al, 2008, Fertil Steril, in press
Fertility preservation strategies offered for women
at MRC with cancer
Chemotherapy cannot be delayed and/or hormonal
stimulation contraindicated
Immature oocyte retrieval
IVM
Male partner available
(ICSI)
No male partner available
Male partner available
No male partner
Embryo cryopreservation
Ooycte vitrification
Embryo cryopreservation
Ooycte vitrification
Chemotherapy can be delayed and hormonal
stimulation not contraindicated
Ovarian stimulation mature oocyte
retrieval
Ovarian wedge resection or
oophorectomy
Immature oocyte retrieval from ovarian tissue
Ovarian tissue cryopreservation
Obstetric and perinatal outcomes of the IVM
pregnancies
Outcome of IVM, IVF, ICSI and normal pregnancies
• obstetrical and perinatal outcome of 432 babies (55 IVM, 217 IVF, 160 ICSI) compared with 1,296 age-matched spontaneous pregnancies (controls) delivered at a single hospital (MUHC)
Buckett et al.Obstet Gynecol 2007; 110:885-91
Perinatal outcome
IVM IVF ICSI Controls p-value
Twin pregnancy rate 12.0% 16.0% 14.0% 1.3% p<0.001
Triplet pregnancy rate 4.0% 2.0% 3.0% 0 p<0.001
Mean birthweight (g) 2,812 2,826 2,801 3,289 p<0.001
Mean gestational age (wks) 37 37 36 39 p<0.001
Mean Apgar scores at 1 min 8 8 8 8 n/s
Mean Apgar scores at 5 min 9 9 9 9 n/s
Mean cord pH 7.29 7.30 7.30 7.29 n/s
Congenital abnormalities following IVM (n=55)
Major malformations 2
• ompalocele• small ventricuoloseptal defect
1
1
Minor malformations 3
• patent ductus arteriosus 1
• congenital hip dislocation 2
Relative risk for any congenital abnormality compared with controls
RR 95% CI
IVM 1.19 0.35 – 3.25
IVF 1.01 0.52 – 1.90
ICSI 1.41 0.72 – 2.68
Pregnancy outcomes per clinical pregnancy after IVM, IVF and ICSI
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Live Birth (p<0.05) Miscarriage(p<0.005)
Ectopic Late PregnancyLoss
Miscarriage inPCOS (NS)
IVM IVF ICSI Buckett et alFertil Steril 2007
Pregnancy Outcome in IVM
• Mikkelsen et al. (2005) ----- 47 IVM babies– 2 twins– 1 NT Normal karyotype– 2 preterm deliveries– 1 stillbirth (42 weeks)– 1 chromozomal abnormality
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
Deliveries and ongoing pregnancies(facts and educated guesses)
Countries Deliveries and ongoing pregnancies
Scandinavia 150
Italy 77
France 40
Germany 20
Rest of Europe 33
Total Europe 320
Deliveries and ongoing pregnancies(facts and educated guesses)
Countries Deliveries and ongoing pregnancies
Middle East 21
Japan 100
Vietnam 26
China (incl. HK) 60
Korea (Cha Hosp.) 57
Korea (Maria Cl.) ≈ 400
Rest of Asia 15
Total Asia 679
Deliveries and ongoing pregnancies(facts and educated guesses)
Countries Deliveries and ongoing pregnancies
Canada 120
USA 5
Australia 5
Total 130
Deliveries and ongoing pregnancies(facts and educated guesses)
Countries Deliveries and ongoing pregnancies
Asia 679
Europe 320
North America 125
Australia 5
Grand Total 1129
- one year ago !
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
Conclusions
• IVM simplifies treatment, reduces costs and eliminates OHSS
• IVM successful in women with high AFC
• hCG increases final number of MII oocytes and rate of maturation
• IVM may be helpful in women with repeated poor embryo quality in previous IVF cycles for no obvious reason, or repeated poor responders to ovarian stimulation
Conclusions
• IVM produces CPR/C of 35%, and up to 48% in selected cases, in women up to 35 .
• obstetric and perinatal outcomes of IVM pregnancies comparable with IVF and ICSI
• IVM may be useful for oocyte donation or PGD
• IVM may offer a chance for fertility preservation to young women with cancer and undergoing cytotoxic treatment.
• IVM may not replace standard IVF but appears to play increasingly important role in ART
Acknolwedge
Dr. Ezgi Demirtas
Reproductive Centre
McGill University