The Women’s Clinic 婦產科中心 Current Criticism on IVM Treatment Dr. Milton Leong MDCM DSc (McGill) Director, IVF Center, Hong Kong Sanatorium & Hospital Specialist

The Women’s Clinic

婦產科中心

Current Criticism on IVM Treatment

Dr. Milton Leong MDCM DSc (McGill)

Director, IVF Center,

Hong Kong Sanatorium & Hospital

Specialist in Reproductive Medicine

Adjunct Professor, OBS-GYN, McGill University

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婦產科中心

Current Criticism of IVM

Lower fertilization rateLower pregnancy & implantation rates

Higher pregnancy lossInadequate neonatal and postnatal data

Possible genetic and epigenetic changes


婦產科中心

Current Criticism of IVM

Inconsistent pregnancy ratesInconsistent clinical details regarding timing, endometrium, EC techniques

Inconsistent laboratory details regarding EC, culture system and culture techniques

Inertia from IVF success vs “experimentation”


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Current Status of IVM

Like IVF 25 years ago, IVM is a treatment tool waiting to be universally applicable. At the moment, there is some sort of alchemy bias.

There are also unresolved issues, like IVF then, that needs to be clarified.


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• IVM is a CONCEPT• IVM is a laboratory technique, not a stand alone treatment modality

• IVM is a method of preparing oocytes so IVF can be carried out

• IVF/M have its advantages over conventional IVF in some patients

• IVM can enable IVF to be performed when otherwise it is impossible


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Similar to IVF in 80’s, issues regarding IVM:

• Technical - timing of EC aspiration technique

drugs to use• Laboratory - culture system• Outcome - now there is IVF to compare

• Safety - baby registry long term genetic changes


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Progress in IVM Edwards 1965 : 1st in vitro matured oocyte

Veeck 1983 : 1st IVM pregnancy from an ovum derived from a stimulated cycle

Cha et al. 1991 : the first pregnancy from in-vitro matured oocytes derived from a caesarean section donor

Trounson et al. 1994: IVM in women with PCOS

improvements in culture condition and transfer techniques have demonstrated that IVM is an effective treatment for women with PCO or PCOS.

In general, clinical pregnancy and implantation rates for infertile women with PCO or PCOS have reached approximately 30-35% and 10-15%, respectively, (Chian et al., 2004).


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Advantages of IVM

• No/minimal stimulation: less OHSS less long term effect safety factor – cancer patients• Flexible start time, no preparation• Cancer patients no theoretical and actual risk (especially breast ca)

can treat anytime


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Indications for IVFM treatment

• Polycystic ovaries (PCO) or polycystic ovary syndrome (PCOS) (primary);

• Hyper responders for gonadotropin stimulation (alternative);

• Delayed responders for gonadotropin stimulation (alternative);

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PCOS and IVF

• Pregnancies were comparable to non-PCOS patients

• Lowered fertilization rate• Increased miscarriage rate• FSH requirement leads to under or over

response• Higher cancellation rate• Much higher chance of OHSS


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PCOS, OHSS and IVF

• Risk up 5-30 fold (6-30%)

• Estradiol >3000pg/ml

• # Follicles >20


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OHSS in PCOS Undergoing IVF

• Preventive Measures:

• Pre-treat with laparoscopic drilling• Use GnRH-ant then GnRH-a to trigger• Metformin (as short as 28 days)• No Transfer, Cryopreservation• Early Aspiration of Follicles - 2 operations

• Conversion to IVM• IVM with and/or without stimulation


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GnRHa v.s. HCG in IVF-IVF used in PCOS

300 ųg Buserelin vs 10000 unit HCG

Maturation rate same(±50%)

Fertilization rate same 85%

Pregnancy rate same 41%

OHSS rate < 1%

A. Fukuda et al, Fertility and Sterility 2008

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IVM/IVF vs IVF for PCOS

Child TJ, et al,2002


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IVM-IVF in POS

210 cycles

1883 oocytes 56% maturation

83% fertilization

Pregnancy rate31% fresh

32% frozen-thawed

50/56 pregnancies delivered

Miscarriage 11%

A. Fukuda et al, Fertility & Sterility 2008

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McGill IVM results by age group McGill IVM results by age group (own oocytes only – patients with PCOS)(own oocytes only – patients with PCOS)

AgeAge

(years)(years)

Implantation Implantation rate per rate per embryoembryo

Clinical Clinical pregnancy rate pregnancy rate

per cycle startedper cycle started

Live birth Live birth rate per cycle rate per cycle

startedstarted

<35<35 14.4%14.4% 34.8%34.8% 20.0%20.0%

35-3735-37 5.4%5.4% 20.0%20.0% 20.0%20.0%

38-4038-40 5.0%5.0% 20.0%20.0% 10.0%10.0%

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Obstetric and perinatal outcomes of the IVM

pregnancies


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Updated IVM success rates

• Clinical pregnancy rate 30-35% per ET;• Implantation rate 9-15% per ET;• More than 1,000 healthy live births;

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Pregnancy Outcome in IVM

• Malformation:– Cha, Fertil. Steril. 2005 5,3% major

malformation

rate

• Later neuromotor development:– Soderstrom-Anttila, Hum. Reprod. 2006

))) Minor developmental delay at first year

))) No Difference in the second year

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Outcome of IVM, IVF, ICSI and normal pregnancies

• obstetrical and perinatal outcome of 432 babies (55 IVM, 217 IVF, 160 ICSI) compared with 1,296 age-matched spontaneous pregnancies (controls) delivered at a single hospital (MUHC)

Buckett et al.Obstet Gynecol 2007; 110:885-91


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Perinatal outcome

IVM IVF ICSI Controls p-value

Twin pregnancy rate 12.0%16.0% 14.0%

1.3% p<0.001

Triplet pregnancy rate 4.0%2.0%

3.0% 0 p<0.001

Mean birthweight (g) 2,812 2,826 2,801 3,289 p<0.001

Mean gestational age (wks) 37 37 36 39 p<0.001

Mean Apgar scores at 1 min 8 8 8 8 n/s

Mean Apgar scores at 5 min 9 9 9 9 n/s

Mean cord pH 7.29 7.30 7.30 7.29 n/s


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Congenital abnormalities following IVM (n=55)

Major malformations 2

• ompalocele• small ventricuoloseptal defect

1

1

Minor malformations 3

• patent ductus arteriosus 1

• congenital hip dislocation 2


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Relative risk for any congenital abnormality compared with controls

RR 95% CI

IVM 1.19 0.35 – 3.25

IVF 1.01 0.52 – 1.90

ICSI 1.41 0.72 – 2.68


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Pregnancy Outcome in IVM

• Mikkelsen et al. (2005) ----- 47 IVM babies

– 2 twins– 1 NT Normal karyotype– 2 preterm deliveries– 1 stillbirth (42 weeks)– 1 chromozomal abnormality


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Worldwide IVM babies born (2007)

Korea 455

Taiwan 20

Colombia 7

Canada 131

Finland 52

Turkey 8

China 58

Japan 51

Vietnam 42

Hong Kong 18

Denmark 34

Italy 56

UK 8

Total 930


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Drawbacks in IVM

– Lower development competence– Lower blastocysts formation– Lower implantation rate– Lower pregnancy rate– Higher miscarriage rate

But, where is the beef?

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Development Competence of Oocytes

1. Nuclear maturation – progression to Meta phase II stage.

2. Cytoplasmic maturation – coordinated arrangement of proteins, organelles.

Gosden R et al, Bioessays 1997

Nogueira D et al, Fertil Steril 2007

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Development Competence of Oocytes

1. IVM results in asynchronous nuclear vs. cytoplasmic maturation

2. IVM (mouse oocytes) showed different spindle morphology when assessed with immuncytologic staining.

Combelles CM et al, Human Reprod 2002

Sanfins A et al, Biol Reprod 2003

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Results of the spindle and chromosome analysis in both experimental groups.

No.(%) of oocytes with No. (%) of oocytes with

Oocyte Group Spindle configuration Chromosome configuration

Normal Abnormal Normal Abnormal

Oocytes matured in vitro 27(56.3) 21(43.7)a 32(66.7) 16(33.3)a

(n = 48)

Oocytes matured in vivo 19(86.4) 3 (13.6) 20(90.9) 2(9.1)

(n = 22)

aP<.05 vs. oocytes matured In vivo.

Li. Spindle and chromosome configurations of human oocytes. Fertil Steril 2008

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Does size matter

– In vivo matured oocytes > immature.– Maturation rate (IVM) related to diameter

of oocytes.– Zona thickness, total oocytes + zona

diameter has no correlation.

Cavilla JL et al, Human Reprod 2008

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Outcome of IVM

– In mouse, in vitro vs. in vivo maturation.– In vitro: a) established optimized culture fluid

b) no amino acid culture fluid– Comparing life span, and variety of physiological and

psychological tests.– No difference between in vitro or in vivo life span or

behavior.– In culture fluid a) reduction in cardiac output and

pulse rate.

Eppig JJ et al, Human Reprod 2009

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Outcome of IVM

21 children IVM vs. non IVM, age 2-5PE – neurological examination and developmental (Bayley

Scales)

Findings:Normal Karyotype, Normal PEMean Mental Developmental Index Score 92.7% vs. 97.2%,Mean Psychomotor Development Index Scores 96.7% vs.

96.2%.Conclusion: No developmental delay in infancy and early

childhood

Shu-chi M et al, Early Hum Dev 2006

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Outcome in IVM

46 children assessed at 6, 12, 24 months

Muenchener Funktionelle Entwicklungs Diagnostik and Bayley Scales

6 mths Normal12 mths 19% IVM expressed minor

developmental problem1/43 had optic glioma

24 mths Normal development

Suikkari M et al, Human Repro 2006

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Outcome of IVMIVM vs. IVF vs. ICSI

N = 1581 IVM IVF ICSI

Biochemical loss 17.5% 17% 18% ND

Clinical miscarriage rate

25.3% 15.7% 12.6% SD

Ectopic preg. 1% 2.3% 1.8% ND

Late foetal loss 1% 2.7% 2.9% ND

PCOS 24.5% 22.2% ND

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Buckett WM et al, Fertil Steril 2008


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IVM outcome

High miscarriage rate may be due to other causes (endometrium?) because cytogenetic and DNA fragmentation analysis of the aborted embryos were not different from routine IVF.

Benkhalifa Meta, Reprod Biomed Online 2009

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Genetics in IVM

Methylation of the KCNQ1OT1 gene in vitro matured oocytes methylate DNA the same as GV and mature genes.

At 28 hours of culture, however, GV and MI oocytes from natural cycles significantly methylate more than those from stimulated cycles.

?Hyperstimulation recruits too young follicles

Khoueiry R, J Med Genet 2008

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Genetics in IVMNo difference in meiotic spindle organization, chromosome alignment and aneuploidy

(mouse oocytes)

Xu L et al, Syst Biol Reprod Med. 2008

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Effect of IVM on Genes

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Genes and IVM

Rhesus Monkey oocytesIVM vs. VVM

Only 56 mRNA’s differentially expressed. These are related to cell homeostasis, cell-cell interactions, cell adhesion, mRNA stability and translation.

Over expression of maternal genes.

IVM oocytes can be very close to VVM oocytes but interruption of normal oocyte-somatic cell interaction may disturb full developmental competence.

Lee YS et al, Physiol Genomics 2008

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Genes and IVM

IVM, then examine GV, MI, MII oocytes, using H19. Differentially methylated region

GV UnmethylatedMI Arrested – altered methylation patternMII 15/20 normal unmethylated pattern

5/20 methylated pattern

Risk of epigenetic changes so safety of IVM should be assessed.

Borghol N et al, Genomics 2006

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Genes in IVM

Although in vivo maturated an in vitro maturated oocytes has very similar gene expression, the major difference is in persistence of immature genes.

IVM oocytes differs in gene expression related to cytoplasmic function and cellular storage and homeostasis.

Well D et al, Am J Obstet Gynecol. 2008

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IVM successes

– PCOS patients– Natural cycle IVF/M– Birth after vitrification– Repeated successful pregnancies in same

patients– Birth after preservation of oocytes for

cancer patients

McGill Reproductive Centre

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• IVM is efficient infertility treatment,

especially for patients with PCO/PCOS;

• IVM provides an alternative for some patients during ovarian stimulation cycles.

Conclusions

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Conclusions• IVM simplifies treatment, reduces costs and eliminates

OHSS

• IVM successful in women with high AFC

• hCG increases final number of MII oocytes and rate of maturation

• IVM may be helpful in women with repeated poor embryo quality in previous IVF cycles for no obvious reason, or repeated poor responders to ovarian stimulation


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Conclusions• IVM produces CPR/C of 35%, and up to 48% in selected

cases, in women up to 35 .

• obstetric and perinatal outcomes of IVM pregnancies comparable with IVF and ICSI

• IVM may be useful for oocyte donation or PGD

• IVM may offer a chance for fertility preservation to young women with cancer and undergoing cytotoxic treatment.

• IVM may not replace standard IVF but appears to play increasingly important role in ART


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An established treatment for PCO/PCOSIn experienced hands closing on IVFNeeds registry outcome and follow upSome animal data regarding genetic

changesMay be epigenetic changes

All can be solved by proper practice and follow up and large data collection as in

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The Women’s Clinic 婦產科中心 Current Criticism on IVM Treatment Dr. Milton Leong MDCM DSc (McGill) Director, IVF Center, Hong Kong Sanatorium & Hospital Specialist