Ovarian Ageing: mechanisms and clinical

consequencesReproductive Ageing: a basic and clinical update

SSIF, Taormina, April 29 and 30, 2011

Frank J BroekmansProfessor Reproductive Medicine and Surgery

University Medical Center Utrecht 35

Health risks associated with menopause

Early menopause is related to:• Cardiovascular disease

• Decreased bone density

• Colorectal cancer

• Infertility

Late menopause is related to:• Breast, endometrial and ovarian

cancer

Hartge, 2009

Questions

• What do we know about mechanisms of Ovarian Ageing?

• How are quantity and quality decline in Ovarian Ageing related?

• Are reliable Markers available for estimating Ovarian Age?

• Can these Markers help us in Clinical Conditions?

• Conclusions

Reproductive Ageing = Ovarian Ageing

Not CNS Ageing

Phases Ovarian ageing process

Soules FS 2001

Age in yrs 13 45 51

Primordial follicle number

1

10

100

1000

10000

100000

1000000

10000000

12

weeks

18

weeks

40

weeks

10 20 30

years

40 50 60

Fetal LifePre

puberty Regular cycles Irregular

990.000

Fetal Life

6.000.000

Extra-Uterine life

Follicle wastage at high speed

Menopause..

Distribution of Age at Menopause

Age at Menopause

62,0554,2446,4338,6230,8123,00

Fre

qu

en

cy

of

Occu

rrence

400

300

200

100

0

and its variation…

final cessation of

cyclic ovarian

function

Is variation in AMP caused by difference in

peak numbers of follicles?? Wallace, PLOSone2010

Pro

po

rtio

n o

f p

oo

r q

ual

ity

oo

cyte

s(%

)

102

103

104

105

106

Nu

mb

er o

f fo

llicl

es

107

0 10 20 30 40 50 60

50

75

100

25

Age (years)

Optimalfertility Declining

fertility End of fertility

Irregularcycles

Number of follicles

Proportion of poor quality oocytes

Menopause

Ovarian Ageing = Quantity and Quality

Decline of Follicles and Oocytes with age

Redrawn after de Bruijn, te Velde. In: Preservation of fertility. London, Taylor & Francis, 2004:3.

Fecundity declines with female age

Evidence from

Natural Populations

Rate of haploidy and the incidence of aneuploidy according to

maternal age in a sample of 1,397 human oocyte II karyotypes.Pellestor, CCI 2005

Resumed meiosis is increasingly

defective with higher female age

young egg donors

old egg donors

First meiotic spindles in oocytes Volarcik, 1998

The issue is Variability

Age at last child in Natural Fertility

population: variability Broekmans 2004, Bouchard 1994

Distribution of Age at Menopause

Age at Menopause

62,0554,2446,4338,6230,8123,00

Fre

qu

en

cy

of

Occu

rrence

400

300

200

100

0

Distributions of age at:

Age last child

Onset Cycle Irregularity

Natural Menopause

Broekmans, 2009

Treloar, 1981

den Tonkelaar, 1998

Parallellity and Variation

in Reproductive Events

Source of Variation

FolliculogenesisContinuous

Intermittent

Multiple environmental AND genetic factors

COMPLEX TRAIT

• Environmental factors:

• Smoking

• Iatrogenic

• Genetic factors:

• Multiple genes involved

• Heritability 65-80%

Rosen, MP 2010

Source of Variation

Snieder, 1998; de Bruin, 2001; van Asselt 2004

What do we know about mechanisms of

Ovarian Ageing?

Follicle wastage largely Unnoticed

Oocyte quality decline reducing Fertility

Variability

Genetic factors dictate Quantity

Questions

• What do we know about mechanisms of Ovarian Ageing?

• How are quantity and quality decline in Ovarian Ageing related?

• Are reliable Markers available for estimating Ovarian Age?

• Can these Markers help us in Clinical Conditions?

• Conclusions

OMEGA study

Vd Gaast, RBM 2006

Poor Responders to hyperstimulation have

poorer oocyte and embryo quality

Artificial Reduction in Quantity – Mice

experiments

Ovx Mice:

• Earlier onset of

irregular cyclicity

• Earlier onset of

aneuploidy

Difference age

independant

Brook, HumGen 1989

The poor responder in IVF: is the

prognosis always poor? Age matters!!!

A systematic literature review.

Oudendijk and Yarde, Submitted 2011

Author Female age

28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 >46

Biljan et al. 2000 27.8% 4.2%

Galey-Fontaine et al. 2005 14.6% 4.9%

Hanoch et al. 1998 19.3% 6.0% 6.5%

Inge et al. 2005 27.1% 12.7%

Rooij, van et al. 2003 13.0% 4.0%

Saldeen et al. 2007 14.0% 3.0%

Sutter, de et al. 2003 23.0% 12.0%

Ulug et al. 19.5% 7.2% 1.5%

Yih et al. 2005 35% 21% 17% 11%

Zhen et al. 2008 18.5% 2.8%

Female age and pregnancy rate per cycle started in Poor Responders (n=3200)

Poor Response relates to Miscarriage Rate in

ART pregnancies, effect is age related

Haadsma, RBM 2010

Age matched relation between Ovarian

Response or Surgery and Odds for Trisomy

Odds For Trisomic Pregnancy

0

0,5

1

1,5

2

2,5

3

3,5

4

4,5

5

1 to 4 5 to 8 ≥ 9 reference

Response Categories (oocyte number)

Od

ds

Ra

tio

Odds for Trisomic Pregnancy

0

0,5

1

1,5

2

2,5

3

3,5

yes no

Previous Ovarian SurgeryO

dd

s R

ati

o

Haadsma, 2009

Expected =

abnormal ORT

(FSH AMH AFC

InhB)

Poor Responder and

Cumulative OPRates

Probability Ongoing Pregnancy

in IVF cycle 2 or 3

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

25 30 35 40 45

Female Age

P

PR

NR

Exp PR

Unexp PR

Hendriks, RBM 2008

Optimal FertilityDeclining

fertility

Menopausal

Transition

Age (years)

Num

ber

of

Folli

cle

s

Poor

Oocyte

Qualit

y R

ate

100%

80%

40%

60%

20%

0%

106

105

104

103

102

5020 30 40 60

Post Menopause

End of Fertility

The concept of Quantity and QualityBroer, Academic Thesis, 2011

How are quantity and quality decline in

Ovarian Ageing related?

Variability may be dictated by

different mechanisms

Female age interferes with the

effect of quantity

Questions

• What do we know about mechanisms of Ovarian Ageing?

• How are quantity and quality decline in Ovarian Ageing related?

• Are reliable Markers available for estimating Ovarian Age?

• Can these Markers help us in Clinical Conditions?

• Conclusions

A good marker describes

the wastage pattern of the

primordial follicle pool:

Menopause Prediction –

Reproductive Lifespan

Pro

po

rtio

n o

f p

oo

r q

uali

ty o

oc

ytes

(%)

102

103

104

105

106

Nu

mb

er

of

follic

les

107

0 10 20 30 40 50 60

50

75

100

25

Age (years)

Optimalfertility Declining

fertility End of fertility

Irregularcycles

Number of follicles

Proportion of poor quality oocytes

Menopause

A good marker should

correctly predict oocyte

quality and ongoing

pregnancy prospects:

Current Fertility Prediction

100

Age

Variation in age at menopause and

preceding reproductive events

0

50

25

75

41 51 6121

Cu

mu

lati

ve

%

31

100

Age

Menopause and Natural Sterility have fixed

time relation: reproductive lifespan prediction

0

50

25

75

41 51 6121

Cu

mu

lati

ve

%

31

Te Velde, HRU 2002

Broekmans, 2009

Treloar, 1981

den Tonkelaar, 1998

Does the similarity imply interrelationship

at the individual level??

Distributions of age at:

Age last child

Onset Cycle Irregularity

Natural Menopause

Poor Quantity = Early Menopause

De Boer, HR 2002

Broekmans, End Rev 2009

Relation Age MP and onset Cycle

irregularity Lisabeth, JCE 2004

Ovarian reserve tests

• Female age……

• Basal Hormones

FSH, Anti-Müllerian Hormone (AMH)

• Sonographic parameters

Antral follicle count (AFC)

6-10 mm

2-5 mm

0,1-2 mm

Primordial pool

Primary follicles

Pre-antral follicles

Circulating AMH

?

Broekmans, ER 2009, Broer, COOG 2010

the AFC

Markers according to STRAW Broekmans, 2010

Are reliable Markers available for estimating

Ovarian Age?

Direct Quality markers are absent

For the purpose of

Current Fertility prediction

Quantitative markers may fail..

Future Fertility Prediction

Quantitative markers are promising..

Questions

• What do we know about mechanisms of Ovarian Ageing?

• How are quantity and quality decline in Ovarian Ageing related?

• Are reliable Markers available for estimating Ovarian Age?

• Can these Markers help us in Clinical Conditions?

• Conclusions

AMHLab test

Cycle stable

Assay!!!!!!!!

AFCClinical test

Cycle stable

Standardisation!!!

Response prediction IVF

Accuracy Hyperresponse prediction

Broer, 2009, 2010

Searching for the zero prognosis

patient

Individual Patient Data

Analysis: the IMPORT study

Female age

with or without any ORT

fails to predict accurately

zero prognosis cases

N=5500

Current Fertility Prediction

AUC

Age 0.57

AFC 0.50

AMH 0.55

Age + AFC 0.58

Age + AMH 0.57

Female age and AMH in concert may

indicate levels of prognosis for live birth

Future Fertility = Menopause Prediction

FollowUp Data

T1 T212 years

1996/1997 2008/2009

255 women with

proven fertility, 22-46

years and regular

cycles at T1 AMH

measured

Broer, JCEM, 2011

Predicting age Menopause from age and

AMH Broer JCEM, 2011

High age specific AMH

Shift towards higher age

at menopause

Low age specific AMH

Shift towards younger

age at menopause

Steiner, Menopause 2008

MP age of mother affects the ovarian

reserve conditions of the daugther (at average 40)

Family History

Messages

• The variability in timing of ovarian ageing

is considerable and affects fertility and more

• Relation between quality and quantity is

confusing, but likely age dependant

• Markers for ovarian ageing reflect quantity

and poorly reflect fertility (better focus on

Reproductive Life span prediction?)

Frank BroekmansProfessor

Reproductive Medicine and Surgery

University Medical Centre Utrecht

The Netherlands

Simone Broer Jeroen van DisseldorpMonique SterrenburgMarieke VerbergDave HendriksEllen KlinkertIlse van RooijLaszlo BancsiKim Broeze (AMC)Brent Opmeer (AMC)Madeleine Dolleman

Bart FauserNick Macklon (Southampton)

Ben W Mol (AMC)Nils Lambalk (VUMC)

Thank Youthe IMPORT* studygroup

Richard A. Anderson

Mahnaz Ashrafi

László Bancsi,

Ettore Caroppo,

Alan B. Copperman,

Thomas Ebner,

Talia Eldar-Geva,

Mehmet Erdem,

Ellen M. Greenblatt,

Kannamannadiar.

Jayaprakasan,

Nick Raine-Fenning,

Ellen Klinkert,

Janet Kwee,

Antonio La Marca,

MyvanwyMcIlveen,

Luis T. Merce,

Shanthi Muttukrishna,

Scott M. Nelson,

Ernest H.Y. Ng,

Biljana Popovic Todorovic,

Jesper M.J. Smeenk,

Candido Tomás

Paul J.Q. Van der Linden,

K.Vladimirov,

Patrick Bossuyt