In-vitro maturation: patient selection and results

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In-vitro maturation patient selection and results

• Aygul Demirol
• Assoc Prof, Medical Director
• GURGAN CLINIC IVF Center, Ankara-Turkey

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In-vitro maturation (IVM)

• Immature oocyte retrieval and subsequent oocyte
  maturation in vitro without any ovarian
  stimulation

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IVM (in-vitro maturation)

• In 1991, Cha et al. reported a pregnancy from IVF
  with oocytes obtained from ovariectomy specimens
  and matured in culture (healthy triplet girls)
  (Cha KY, Fertil Steril 1991)

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IVM (in-vitro maturation)

• Trounson et al. reported the birth of a normal
  baby with IVM of immature oocytes from a
  polycystic ovary syndrome (Trounson Fertil Steril
  1994)

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IVM (in-vitro maturation)

• There have been more than 1000 births of babies
  with IVM procedures, including in patients with
  PCOS
• (Chian RC)
• BUT, IVM has not become mainstream in IVF, with
  ovulation induction cycles with oocyte retrieval
  of mature (MII) oocytes still the highly favored
  protocol.

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Why IVM ?

• Reduced cost
• Avoiding OHSS
• Simplification of treatment compared with
  conventional IVF-ET

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IVM Indications

• PCOS
• High responders
• IVF/IVM
• Fertility preservation
• Donation cycles
• Delayed responders
• Male infertility
• Poor responders

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2-12 mm follicles
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• In general
• clinical pregnancy rate 30-35
• implantation rate 10-15
• (R.C. Chian RBM Online, 2004)

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IVM

• 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

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IVM is based on the treatment of

• Two main groups of patients
• With PCO (have irregular, mostly anovulatory
  cycles and are at increased risk for OHSS because
  of their higher sensitivity to gonadotropins)
• With normal ovaries (may wish to avoid the
  side-effects of hormone injections)

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How to maximize IVM results byoptimizing
clinical management

• Patient selection criteria-best candidates
• Under 35 years of age
• PCO/PCOS

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Patient management-I

• Baseline TV-USG (day 2, 3)
• Second USG (between day 6 and day 9)
• (for follicular and endometrial assessment)
• HCG priming 36 hours prior to egg collection

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Patient management-II

• IVM ovum aspiration needle, single or double
  lumen, 19 G, 35 cm
• Aspiration pressure 85-100 mmHg
• All visible follicles are aspirated

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Patient management-III

• Priming with FSH or HMG ?
• Priming with HCG ?

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FSH Priming

• Results are conflicting
• Potential benefits
• Larger ovarian size
• Easier retrieval
• Higher E2 levels
• More maturational competence

May lead to improved endometrial priming
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HCG Priming

• Theoretically HCG priming
• Promote invitro maturation
• Improve pregnancy rates

However the exact mechanism of HCG on small
follicles is still unclear
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HCG Priming

• First prospective study
• Chian et al. (2000)

• Increased oocyte maturation
• High clinical pregnancy rate
• ( 36 )

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hCG Priming

• In-vitro maturation rate is faster in oocytes
  obtained from hCG primed IVM oocytes.
• (Chian et al.,Human Reprod ,2000 Son et
  al., RBM Online,2006)
• - Hastens the the oocyte maturation in-vitro
• - Makes the oocyte retrieval easier
• Mature oocyte on the day of retrieval is higher
• (Son et al.,Hum.Reprod,2002)
• Higher fertilization,cleavage and blastocyt
  development rates in IVM cycles
• Number of good quality blastocysts higher (40 vs
  23.3) (Son et al.,RBM Online,2008)

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Lab management-I

• Determination of cumulus-oocyte complexes (COCs)
  (special sliding technique-after using cell
  strainer)
• The immature COCs are incubated in culture dish
  containing 1 ml oocyte maturation medium
  supplemented with a final concentration of 75
  mIU/ml FSH and 75 mIU/ml LH
• for SAGE medium

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Lab management-II

• For MediCult medium, preincubation in LAG medium
  (2-3 hours)
• Transferring into IVM final maturation medium (9
  ml IVM medium is added 1 ml patient serum, 10 µl
  pregnyl, 100 µl FSH)

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Lab management-III

• Stripping oocytes 24 hours after culture
• Twenty for hours after maturation additional 24
  hours for immature COCs
• Mature oocytes are subjected to ICSI
• Embryo maintenance medium for SAGE
• ISM1 for MediCult

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Endometrial priming

• 17-ß-oestradiol starts on the day of OPU (2 mg
  orally, three times daily and continue until
  pregnancy test)
• Two days after OPU, intravaginal progesterone
  suppositories 600-800 mg, daily and continue
  until pregnancy test)

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Clinical outcome for PCO/PCOS
Jurema MW. Fertil Steril 200686127791.
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Clinical outcome for normal ovaries
Jurema MW. Fertil Steril 200686127791.
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Pregnancies and deliveries after transfer of
humanblastocysts derived from in vitro matured
oocytes inIVM ( PCO(S) ) (Blastocyst vs cleavage
ET)
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• The abortion rate, gestational age and birth
  weight at delivery, and obstetric complications
  of pregnancies conceived by IVM-ET in women with
  PCOS were comparable with those of other women
  with PCOS being treated by conventional IVF-ET
• (Fertil Steril, 2005)

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CONCLUSION Compared with IVF and ICSI, IVM is
not associated with any additional risk. (Obstet
Gynecol 200711088591)
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Outcome of the IVM cycles (sept 2005-jan 2010)

• GURGAN CLINIC IVF Center
• Ankara, Turkey

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n mean Mean age 30.2 Cycles 321 Cyc
les with oocytes 321 100 Oocytes retrieved
2725 8.7 24 h maturation Oocytes reaching
MII 1253 47.1 4.2 Oocytes fertilized(2PN) 989
79.2 3.08 Embryos cleaved 890 90.1 48 h
maturation Oocytes reaching MII 408 15.3 1.2 Ooc
ytes fertilized (2PN) 301 74 Embryos
cleaved 210 70.2
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n mean transfer and
outcome Cycles with embryo transfer
288 90.4 Embryos transferred 806
2.8 Biochemical pregnancies/transfer
103 36.1 Clinical pregnancies/transfer
78 27.1 Implantation rate 13.4 Ongoing
pregnancies 41 Live birth 16 Abortion
rate 21 26.9
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Immature oocyte after oocyte pick-up
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Mature oocytes after denudation ICSI
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Fertilised (2 PN)oocytes
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Cleavage stage (Day 2) embryos
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Blastocyst stage (Day5)
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PREGNANCIES IN TURKEY FOLLOWING IN VITRO OOCTYE
MATURATION

• Aygul Demirol, Tamer Sari, Bagdagul Girgin,
  Erkin Kent, Suleyman Guven, Timur Gurgan
• 2007, GORM
• Two women with history of infertility and PCOS
  underwent in vitro maturation (IVM) program
  without controlled ovarian hyperstimulation. The
  patients were primed with 10.000 IU HCG 36 h
  before oocyte retrieval. Oocytes-cumulus masses
  were matured in IVM medium. The matured oocytes
  were fertilized by ICSI and embryo transfer was
  performed on day 3

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accepted
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IVM for a Second Chance

• Recent reports
• Risk of OHSS

47 CLINICAL PREGNANCY No OHSS
Lim et al. Fertil Steril 2002
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Natural Cycle IVM

• But natural cycle yields only 1 single follicle
• For other non dominant follicles

IVM may be an option
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Thank you for their help and support

• Ri-Cheng Chian, McGill Reproductive Center,
  Montreal, Canada
• Mette Munk, Jyllinge, Denmark
• and others