The Jones Institute for Reproductive Medicine Founded on Science, Dedicated to Life

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1 The Jones Institute for Reproductive Medicine Founded on Science, Dedicated to Life

2 Assisted reproductive technologies: State-of-the-ART Sergio Oehninger, MD, PhD Professor and Vice-Chair, Dept. Ob/Gyn Director, Division of Reproductive Endocrinology and Infertility The Jones Institute for Reproductive Medicine Eastern Virginia Medical School

3 Assisted reproductive technologies (ART): facts and significance Infertile couples make up approximately 10% of the worldwide population of reproductive age. It is now 35 years since the birth of Louise Brown in Oldham, England, and 33 years since the birth of Elizabeth Carr in Norfolk, VA, the first two IVF babies born in Europe and USA, following a natural cycle and a gonadotropin-stimulated cycle, respectively. Assisted reproductive technologies (ART) currently account for 1.5% of total US live births, and up to 4% in some European countries. More than 5 million babies born

4 33 years!!!

5 50% 40% 30% 20% The efficiency of IVF U.S. trends in Assisted Reproduction over its first 30+ years Donor Egg IVF Cryo 10% 0%

6 Use of initial work up results to guide treatment decisions Diagnosis of Male Infertility Identification of Female Factors Therapeutic Options Urological COH/IUI Medical IVF/ICSI

7 Pregnancy Rate Cumulative pregnancy rates in unexplained infertility, women <40y 60% 50% 40% 30% 20% 10% 0% IVF IUI + Gon IUI + CC IUI CC Months Cost-Efficiency!!!

8 (CDC, 2009)

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10 Hydrosalpinx

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16 Reproduction: It Takes Two to Tango! Basic semen analysis

17 SPERM: Semen Analysis concentration, motility, morphology, others Looks matter!!

18 Obstructive azoospermia Non-obstructive azoospermia 46XY Microdeletions Y Testicular Biopsy

19 Ovarian aging Donor eggs Own eggs Miscarriage 25,000 foll 1,000 foll

20 (CDC, 2009)

21 In Vitro Fertilization principal steps Ovarian Cycle Follicular Phase Luteal Phase Menstrual Cycle Proliferative Phase Secretory Phase Menses recfsh/lh/hmg/hcg [GnRH ag GnRH antag] PGD Embryo Cryopreservation Pregnancy Diagnosis Ovarian Function Serum Estradiol Follicular Diameter Follicular Aspiration US-Guided Transvaginal Retrieval In Vitro Fertilization Insemination ICSI Cleavage Progression Indicative of Viability Transfer Conceptus placed in uterus (ultrasound-guided)

22 Ovarian stimulation protocols for IVF (Knobil, Hodgen) Recombinant Urinary-purified

23 AFC in addition to day 3 FSH and AMH

24 The Author Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please Association between egg number and live birth rate. (Sunkara S K et al. Hum. Reprod. 2011;26: )

25 Normal responders: GnRH agonist + gonadotropins: luteal lupron or long suppression, with OCP overlap rfsh ( IU) OCP/Luteal Lupron Progesterone Day hcg ER ET

26 Normal responders: OCP/Gonadotropins + GnRH Antagonist O C P GnRH antag OCP or not? Fixed vs flexible regimens? Do not decrease gonadotropin dose Add LH? rfsh ( U/d) Progesterone Day hcg ER ET

27 GnRH antagonists for ART (review) The use of GNRH antagonist compared with long GnRH agonist protocols is associated with a large reduction in OHSS and there is no evidence of a difference in live-birth rates OHSS can be erased by applying ovarian stimulation using the combination of GnRH antagonist with GnRH agonist to trigger ovulation. In this case, the strategy is to freeze all of the oocytes or embryos for later use

28 Today s Stimulation Protocols Are Demanding Long GnRH agonist protocol LH Flare-up Pituitary downregulation Direct gonadotropin suppression GnRH antagonist protocol Time Adapted from Borm G et al. Hum Reprod. 2000;15:

29 Corifollitropin alfa, a hybrid molecule with sustained FSH activity and reduced injection frequency (Fauser et al, HRU 2009 Devroey et al, HR 2009)

30 Corifollitropin Alfa Can Initiate and Sustain Follicular Growth for 1 Week 1,2 Corifollitropin alfa Daily FSH injections 1. Duijkers IJ et al. Hum Reprod. 2002;17: Fauser BC et al. Hum Reprod Update. 2009;15:

31 Corifollitropin Alfa Reduces the Number of Necessary Injections 1 rfsh hcg Corifollitropin alfa LH Direct gonadotropin suppression Time rfsh = recombinant follicle-stimulating hormone; hcg = human chorionic gonadotropin. 1. de Greef R et al. Clin Pharmacol Ther. 2010:88:79 87.

32 Patients Corifollitropin Alfa Phase III Clinical Trials ENGAGE 1 ENSURE 2 PURSUE 3 TRUST 4 >60 kg 18 to 36 years 60 kg 18 to 36 years 50 kg 35 to 42 years >60 kg 18 to 39 years Sample Size / Sites Treatment Arms 1,509 Europe 20, North America 14 Corifollitropin alfa 150 µg 397 Europe 14, Asia 5 Corifollitropin alfa 100 µg 1,424 United States 33 Corifollitropin alfa 150 µg sites (Australia, Europe, South America) Corifollitropin alfa 150 µg rfsh 200 IU/d rfsh 150 IU/d rfsh 300 IU/d Design Double-blind RCT 1 cycle Double-blind RCT 1 cycle Double-blind RCT 1 cycle Open-label, uncontrolled Max 3 cycles Primary End Point/Coprimary End Point Ongoing pregnancy rate Number of oocytes Number of oocytes Vital pregnancy rate, assessed 5-6 weeks post-et Immunogenicity, safety 1. Devroey P et al. Hum Reprod. 2009;24: Corifollitropin alfa Ensure Study Group. Reprod Biomed Online. 2010:21: Boostanfar R, et al. Fertil Steril. 2012;98(3):S Norman RJ et al. Hum Reprod May 27. E-pub ahead of print.

33 Ovarian tissue banking Controlled Ovarian Hyperstimulation In vitro oocyte maturation Embryo Cryopreservation Pre-Implantation Genetic Diagnosis Pregnancy Diagnosis Embryo Transfer Follicular Aspiration Egg freezing In Vitro Fertilization ICSI Embryo cleavage

34 Development of human IVF embryos Embryo culture 1-5 days Day 1 1- cell Day cell Day 3 8- cell Day 5 & 6 - Blastocyst

35 Intracytoplasmic Sperm Injection: ICSI ICSI is a safe and effective therapy for the treatment of male factor infertility (ASRM, 2006)

36 High magnification ICSI or IMSI (intracytoplasmic morphologically selected sperm injection)

37 Assisted hatching: laser

38 Egg/embryo freezing Techniques Slow Freezing Vitrification Before cooling Physiological solution Cryoprotectant solution Vitrification solution During cooling 0.3ºC/min Ice seeding Slow cooling Rapid cooling Ultra rapid cooling 200,000ºC/min In LN 2 Nagy ZP. Personal Communication. September 2008.

39 23 C C -196 C -196 C Slow freezing Vitrification

40 Fertility preservation Focuses on helping reproductive-age women and men who are about to undergo cancer treatment understand their risks of infertility and possible treatment options. It can also apply to healthy women who wish to delay child-bearing. IVF with egg or embryo freezing is the recommended therapy at this point for these situations.

41 Selection of embryos for uterine transfer Pronuclear morphology Fast cleavage Day 3 score Blastocyst transfer Embryoscope Invasive methods (PGS) Non-invasive?

42 The EmbryoScope Time lapse system (Unisense, Fertilitech)

43 Time Lapse is heralding a paradigm shift in ART laboratory practices Normal Incubator and Microscope: 4 Observations 17 hrs 27 hrs 44 hrs 68 hrs More Observations Better Selection Less Disturbance Better Development Time-Lapse: Images over 3 days per embryo

44 Selection of embryos with highest implantation competence Non-invasive methods Pronuclear morphology Fast cleavage Day 3 and day 5 scores Embryoscope-Time lapse Identification of biomarkers? OMICS Invasive methods: PGD/PGS Laser Single gene defects (PCR) Chromosomal anomalies (FISH, WGA, array-cgh, SNP-arrays, Q-PCR)

45 ASRM 2008 Practice Committee opinion Recommendations: PGD Genetic counseling must be provided PGD can reduce the risk for conceiving a child with a genetic abnormality carried by one or both parents if that abnormality can be identified with tests performed on a single cell. Prenatal diagnostic testing to confirm the results of PGD is encouraged strongly because the methods used for PGD have technical limitations that include the possibility for a false negative result.

46 JI Results: PGD 90 PGD cycles for single gene mutations all had ET 28/90 pregnancies = 31% 31 babies born no misdiagnoses Single gene defects: Cystic Fibrosis, Tay-Sachs, Spinal Muscular Atrophy, Hemophilia, Fragile X, Muscular Dystrophies, Collagen Gene Disorders, Hemoglobinopathies, Smith Lemli Opitz, Hypertrophic Cardiomyopathy, Fanconi Anemia, Gardner s syndrome, Ocular Albinism, Ornithine Transcarbomylase, Alport, HLA matching, Krabbe, NeuroFibromatosis 2, Von Hippel Lindau, Charcot Marie Tooth

47 Complete Chromosome Screening

48 ACGH Result Report

49 ASRM 2008 Practice Committee opinion Recommendations: PGS Before PGS is performed, thorough education and counseling must be provided to ensure that patients fully understand the limitations of the technique, the risk of error, and the lack of evidence that PGS improves live-birth rates. Available evidence does not support the use of PGS as currently performed to improve live-birth rates in patients with advanced maternal age. Available evidence does not support the use of PGS as currently performed to improve live-birth rates in patients with previous implantation failure. Available evidence does not support the use of PGS as currently performed to improve live-birth rates in patients with recurrent pregnancy loss. Available evidence does not support the use of PGS as currently performed to reduce miscarriage rates in patients with recurrent pregnancy loss related to aneuploidy.

50 IVF: Safety Major risks: Ovarian hyperstimulation syndrome (OHSS) Multiple gestations

51 Iatrogenic Multiples Eli Adashi, MD, 2013

52 Twin Birth Rate Fraction (% of National Twin Birth Rate) Twin Birth Rate Drivers: * 80 Spontaneous OI/OS ART Calendar Year *Adjusted for Maternal Age and Standardized to 1997

53 High Order Birth Rate Fraction High Order Birth Rate Drivers: * (% of National High Order Birth Rate) OI/OS ART Spontaneous Calendar Year *Adjusted for Maternal Age and standardized to 1997

54 A cross-sectional evaluation of the first cohort of young adults conceived by IVF in the USA. Beydoun, Sicignano, Beydoun, Bocca, Stadtmauer, Oehninger. Fertil Steril 2010 Young adults (18-26 years) conceived by IVF (no gamete/embryo manipulation) Target population: 560 young adults (IVF) with a response rate of 31% In conclusion, surveyed young adults appear to be healthy and well-adjusted with no increased susceptibility to cancer or chronic diseases; the relatively high prevalence of clinical depression, ADD/ADHD and binge drinking needs further investigation through large prospective cohort studies.

55 Reproductive Biomedicine On-line 2014 Feb;28(2): Health outcomes of children born after IVF/ICSI: a review of current expert opinion and literature (Fauser et al).

56 IVF-conceived children have lower birth weights and higher peripheral fat, blood pressure and fasting glucose concentrations than controls. Growth, development and cognitive function in assisted-conception children are similar to controls. Catch-up occurs. Small but significant increase in congenital malformations (OR ). The absolute risk of imprinting disorders after assisted reproduction is less than 1%. A direct link between ART and health-related outcomes in assisted-conception children could not be established. Women undergoing ART often older, increasing the chances of obtaining abnormal gametes that may cause deviations in outcomes between assistedconception and naturally conceived children. However, after taking into account these factors, it is not clear to what extent poorer outcomes are due to ART procedures themselves. Large-scale, multicentre, prospective epidemiological studies are needed to investigate this further and to confirm long-term health consequences in assisted-conception children.

57 The role of genetic variance, epigenetic variance and exogenous factors in adverse health outcomes of ART pregnancies and children (Horsthemke and Ludwig, 2005)

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