The intra-follicular molecular biology mandating advancement of egg retrieval in some women

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1 The intra-follicular molecular biology mandating advancement of egg retrieval in some women David H. Barad, USA Director of Assisted Reproductive Technology, The Center for Human Reproduction New York

2 Faculty disclosure Dr. Barad reports royalties from pending and issued patents related to therapeutic benefits from androgen supplementation in women with low functional ovarian reserve (LFOR) and the FMR1 gene in a diagnostic function in female fertility with royalties (all licensed to Fertility Nutraceuticals, LLC), consultant and shareholder in OvaNova Laboratories, and pending patents related to an Anti-Müllerian hormone (AMH).

3 Competent follicles can produce competent oocytes

4 Atresia is a natural process Of thousands of follicles present at puberty only about 400 will reach natural ovulation to produce a mature oocyte

5 Mural and Cumulus granulosa cells

6 Mural and Cumulus granulosa cells Mural Cells Estrogen, AMH, inhibin and Activin Epidermal growth factor Insulin like growth factor Fibroblast growth factors Cumulus cells Bidirectional nutrient transfer and signaling with the oocyte Essential for oocyte maturation and competence

7 Oocyte Granulosa Cell interactions From GAMETES, FERTILIZATION AND EMBRYOGENESIS. Chapter 2 The Mammalian Oocyte David F. Albertini Image is redrawn from McGinnis et al. (2012)

8 Cumulus Cell Gap Junctions

9 Cumulus Cell Gap Junctions Cumulus cells are connected to the oocyte by gap junctions Gap junctions are membrane channels formed by connexins Gap junctions transfer camp, cgmp, amino acids, and RNA transcripts

10 Bidirectional communication Cumulus cells oocyte meiosis resumption nuclear and cytoplasmic maturation transcriptional activity Cumulus cells Oocyte gene expression regulates the growth and atresia metabolism, differentiation, proliferation, apoptosis, and luteinization Differentiation factor 9 (GDF-9) bone morphogenetic protein 15 (BMP-15)

11 Journal of Assisted Reproduction and Genetics

12 Premature Luteinization

13 Patient Characteristics

14 mrna expression Group 1 (oocyte donors) n = 7 ; White columns Group 2 (middle-aged infertile patients) n = 10; Grey columns Group 3 (older infertile patients) n = 10 ; Black columns

15 Timing of Ovulatory Trigger based on age < 38 years old 38 to 42 years old 42 to 44 years old > 44 years old

16 Early Retrieval

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18 Granulosa cells (GCs) in ovarian aging Hypothesis: Age-related reproductive decline is associated with decreasing competence of follicular granulosa cells GCs Steroidogenesis Oocyte Theca cells Pregnancy maintenance Oogenesis

19 Impact of maternal aging on GC gene expression Egg retrieval GCs collection Function analysis

20 Impact of maternal aging on GC gene expression FSH Luteinization R LHR GCs FSHR LHR β-actin older patients GCs is undergoing earlier or faster luteinization.

21 Impact of maternal aging on GC gene expression Down-regulated aromatase and up-regulated PGR expression indicated earlier luteinization

22 GCs in vitro culture test FSH Proliferation apoptosis L-GCs s In vitro culture Cyp19a1 FSHR Only undifferentiated GCs respond to FSH stimulation in vitro; L-GCs do NOT respond GCs: Granulosa cells L-GCs: Luteinized granulosa cells

23 Impact of maternal aging on proliferation and apoptosis of GCs during in vitro culture Without FSH, GCs grow very slowly, especially in older group. FSH can significantly stimulate proliferation in younger groups, but not in older group

24 Impact of maternal aging on proliferation and apoptosis of GCs during in vitro culture Old GCs grow slower in vitro even in the presence of FSH Old GCs have more cell apoptosis and could not be inhibited completely the presence of FSH

25 Impact of maternal aging on gene expression of GCs during in vitro culture FSHR Aromatase FSHR and aromatase can be stimulated by FSH in cultured cells, but response of older GCs was weaker.

26 Pilot study of Early retrieval Standard retrieval (SR) Early retrieval (ER) 22mm hcg trigger 16mm

27 Pilot study of early retrieval Although we got more immature oocytes from early retrieval, we avoided atretic oocytes, had more good embryos and increased pregnancy rate

28 Pilot study of early retrieval Early retrieval reduced luteinization gene markers in older patients.

29 Optimization of early retrieval 1. How early should we trigger in older patients? 2. Does early retrieval work for younger POA patients?

30 Oocyte retrieval at 16-18mm lead follicle size achieves best clinical outcomes in older patients

31 Early retrieval significantly improved pregnancy rates in younger POA

32 Translational Conclusion 1. Early granulosa cell luteinization leads to the declines of IVF successful rate in old patients. 2. Trigger at smaller leading follicle size can reduce the negative effects of early luteinization on IVF outcome mm is the best trigger follicle size for early retrieval. 4. Early retrieval is also a good option for younger POA patients

33 Age Specific adjustment of ovulatory trigger to protect against early luteinization. Take Home Message Follicles undergo earlier luteinization as women age Suppression of the LH surge does not prevent these changes Timing oocyte collection at smaller follicle size is one strategy to prevent collection of atretic oocytes