FRESH OR FROZEN EMBYOS WHAT IS THE LATEST EVIDENCE? DR. ASMA MOMANI CLEVELAND CLINIC, ANDROLOGY LAB TRAINEE 2018

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1 FRESH OR FROZEN EMBYOS WHAT IS THE LATEST EVIDENCE? DR. ASMA MOMANI CLEVELAND CLINIC, ANDROLOGY LAB TRAINEE 2018

3 OBJECTIVES Hisory Indication of freezing embryos Slow freezing versus vitrification Advantages and disadvantages of fresh and frozen cycle Results Take home message

4 IDEA OF FREEZING - limited number of embyos we can transfer, what to do with surplus embyos? - cancellation of ET ( Hyperstimulation, Unfavourable endometrium) - Decrease cost on the couple - PGD ( especially blastocyst,needs time until we get the result )

5 HISTORY first human gamete cryopreservation first live birth with FET first pregnancies with thawed blastocysts Polge et al 1949, Zeilmaker et al 1984, Cohen et al 1985, Chen 1986

6 HOW FREEZING IS DONE? Store in liquid nitrogen at -196 C. To move the embryo from 37 C to -196c we need to use cryoprotectants to prevent cold induced damage to the cells, as a result of their exposure to low temperature. Cryoprotectants are of two types: 1) external: sucrose 2) internal: DMSO, ethyleneglycol

9 ADVANTAGES FOR VITRIFICATION AND FET Allows for better embryo/uterine synchrony Can be scheduled & planned Less stressful for the patient Equivalent or better pregnancy rates to fresh

10 ENDOMETRIAL RECEPTIVITY One of the primary causes cited a better result with FET, was the adverse effect of ovarian stimulation on Endometrial receptivity. The window of implantation is advanced SO Either : No lmplantion Adverse obstetric out come ( low birth weight, PET )

12 UTERINE EXPRESS HAS LEFT THE STATION

13 FRESH VS FROZEN RISK COMPARISON IVF OUTCOME When compared to fresh transfer, frozen-thawed transfer has been associated with: Reduced risk of implantation failure in normal responders Reduced risk of implantation failure following premature progesterone elevation Reduced risk of ivf failure per retrieval Shapiro et al 2011, Shapiro et al 2010, Roque et al 2012.

14 RANDOMIZED TRIAL: FRESH VS FROZEN EMBRYOS 65% clinical pregnancy rate in fresh transfers 80% clinical pregnancy rate in frozen transfers Difference not statistically signicant (p=0.1109) Shapiro et al 2011

18 META ANALYSIS CONCLUSION CONCLUSIONS: The freeze-all strategy could be favorable when high numbers of oocytes are collected, signaling an association between higher ovarian stimulation and consequent impairment of endometrial receptivity. However, when the mean number of oocytes collected is <15, the freeze-all strategy does not appear to be advantageous.

19 THE NEW TREND No fresh transfer at all! Electively freeze all embryos Transfer only in the next cycle Only balstocyst Only vitrification

20 NEED TO WORK TOWARDS THIS Gradual process Need to master the skills Develop confidence in your IVF labs! Training Monitoring Quality control

21 CONCLUSION Data indicates little, if any compromise to embryo Viability with vitrification. Vitrification & FET may allow for better synchrony between embryo & endometrium. Vitrification can match or exceed fresh embyos transfer regarding pregnancy rates.

22 TAKE HOME MESSAGE Individualised approach is needed rather than freeze all protocol. More randomised controlled trials are needed before adopting freeze all protocol.

23 Thank you

(a) Departamento de Ginecologia, Universidade Federal de São Paulo. (b) Centro de Reprodução Humana Fertivitro, São Paulo, Brazil.

(a) Departamento de Ginecologia, Universidade Federal de São Paulo. (b) Centro de Reprodução Humana Fertivitro, São Paulo, Brazil. Human Reproduction Center São Paulo Brasil Aline de Cássia Azevedo (a,b) ; Fernanda Coimbra Miyasato (b) ; Litsuko S. Fujihara (b), Maria Cecília R.M. Albuquerque (b), Ticiana V. Oliveira (b), Luiz Eduardo