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Influence of antral follicle count (AFC) on IVF-ET outcome is modulated by age
pre- and post-implantation fetal growth in animal models has been shown to enhance embryo development and survival. We previously reported that sera from pregnant women induced autophagy in peripheral blood mononuclear cells (PBMCs). In the present study we evaluated whether the extent of autophagy induction by sera of pregnant women would differ according to the outcome of their IVF cycle. DESIGN: We evaluated the extent of autophagy induction by available sera from a retrospective cohort of 94 women who completed an IVF cycle at our institution. The breakdown was 28 women with a term pregnancy, 16 who delivered preterm, 11 with a SAB, 12 with a BC pregnancy, 16 who did not become pregnant and 11 who had an ectopic pregnancy (EP). MATERIALS AND METHODS: Donor PBMCs were isolated from reproductive age healthy female volunteers by Ficoll-Hypaque gradient centrifugation and added to wells of a sterile microtiter plate (5x105 cells per well) that contained 35 ml RPMI culture medium and 15 ml sera from the study subjects. All sera were from day 28 of the IVF cycle, obtained at the time of the initial pregnancy test. As a positive control parallel cultures also contained 4800 mM rapamycin, an autophagy inducer. Following incubation for 48 hours (37 C, 5% CO2) the cells were centrifuged, lysed in the presence of protease inhibitors and stored at -80oC until assayed. The extent of autophagy was determined by measuring the concentration of p62 by ELISA. p62 is a protein whose intracellular concentration is inversely proportional to the extent of autophagy induction. The non-parametric Kruskal Wallis test with Dunn’s correction was used to determine associations. RESULTS:
Autophagy induction in donor PBMCs by sera from women with different IVF outcomes
Median ng/mL p62
(range)
No rapamycin
+ rapamycin
OUTCOME Term birth Preterm birth SAB BC pregnancy Not pregnant Ectopic pregnancy
7.5 (<0.1-20.3) 9.2 (3.1-17.2) 14.8 (9.8-17.2)a 19.1 (9.2-5.4)c 9.6 (2.5-25.9) 3.6 (1.1-18.3)e
2.1 (<0.1-5.7) 1.8 (<0.1-4.3) 5.7 (2.8-13.9)b 4.2 (2.9-7.9)d 2.0 (0.5-7.4) 1.1 (<0.1-9.8)
ap ¼ 0.0005; bp <0.0001; cp ¼ 0.0001; dp <0.0001; ep ¼ 0.0441 all vs. term birth. CONCLUSIONS: Inhibition of autophagy (high p62) was greatest using day 28 sera from women whose IVF cycle ended in a SAB or BC pregnancy. Conversely, sera from women with an EP induced autophagy to the greatest extent (low p62). Rapamycin induced a higher level of autophagy (lower p62) but differences between outcomes were still evident. These observations suggest that deficient autophagy induction may contribute to defective intrauterine implantation in women undergoing IVF. The serum factor(s) responsible for this effect remains to be determined. O-159 Tuesday, October 20, 2015 11:45 AM INFLUENCE OF ANTRAL FOLLICLE COUNT (AFC) ON IVF-ET OUTCOME IS MODULATED BY AGE. A. Oppenheimer, A. Bartmann, V. Genro, J. Nassar, N. Achour-Frydman, R. Fanchin. Division of Reproductive Medicine, Hospital A. Beclere, University Paris-Sud, Clamart, France. OBJECTIVE: As the ovary ages, follicles become progressively scarce and reproductively incompetent but inter-individual variations exist in the pace of follicle loss. Follicle distribution over the various stages of follicle growth also changes with aging, culminating into an increased antral/nongrowing follicles ratio in elderly premenopausal women. Together, these physiologic features concur to explain, at least in part, why some normo-ovulating, non-PCOS women have above-average AFC despite their increasing age. On the other hand, a fraction of young women surprisingly display an under-average AFC. Whether these quantitative variations reflect oocyte competence remains controversial.To clarify this issue, we investigated whether AFC differentially influences IVF-ET outcome in elderly and young patients. DESIGN: Prospective study.
e62
ASRM Abstracts
MATERIALS AND METHODS: We studied selected youngster (26-32 years) and elderly (37-42 years) IVF-ET candidates, regularly-ovulating, devoid of PCOS, and undergoing 863 COH cycles. Prior to COH, all patients had either documented increased (20-24 follicles) or reduced (5-13 follicles) AFC (3-10 mm in diameter in both ovaries) at transvaginal ultrasound scans. According to age and AFC, patients were sorted into 4 groups as follows: Youngster-Increased AFC (n¼167), Youngster-Reduced AFC (n¼208), Elderly-Increased AFC (n¼122), and Elderly-Reduced AFC (n¼366). Clinical pregnancy and live birth rates were the outcome measures. In addition, serum AMH levels were assessed in all patients. Multivariate analysis was performed. RESULTS: Clinical pregnancy and live birth rates were similar in ElderlyIncreased (36.1% and 24.6%, respectively) or Elderly-Reduced (34.4% and 23.2%, respectively) AFC groups. Yet, in the Youngster-Increased AFC group, patients showed an improved IVF-ET outcome (55.1% and 46.7%) as compared to the Youngster-Reduced AFC (37.7% and 30.8%) group (P< 0.001 and P< 0.002, respectively). Multivariate analysis confirmed that only in young patients AFC is related to IVF-ET outcome. Similar results were obtained when using AMH instead of AFC to discriminating ovaries with good or defective follicle endowment. CONCLUSIONS: The present results indicated that, in IVF-ET candidates, the quantity of antral follicles recorded at ultrasound scans reflect the overall follicle health only in young patients (27-32 years). In elderly patients (37-42 years), even marked variations in AFC failed to influence the likelihood of live birth. These data are contributive for orientating clinical practice and raise unanswered questions on the mechanisms regulating the association between follicle quantity and quality during ovarian aging. O-160 Tuesday, October 20, 2015 12:00 PM OPTIMIZING GONADOTROPIN STIMULATION TO MAXIMIZE THE LIKELIHOOD OF OBTAINING EUPLOID EMBRYOS. J. A. Lee,a H. Karvir,b P. Yurttas Beim,c A. B. Copperman.a,d aReproductive Medicine Associates of New York, New York, NY; bCelmatix Inc., New York, NY; cCelmatix Inc, New York, NY; dObstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY. OBJECTIVE: In order to optimize the number of viable oocytes retrieved for IVF, reproductive endocrinologists alter gonadotropin (Gn) dosage and duration of simulation. The ultimate measure of a successful IVF cycle is a euploid embryo. Here we aimed to understand the relationship between commonly adjusted Gn stimulation parameters and the likelihood of obtaining euploid embryos. These insights better enable data-driven personalization of protocols for patients undergoing fertility treatments. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: Patients who underwent fresh IVF with embryo screening (pre-implantation genetic screening (PGS)) from 2009 2015 were included. Binomial regression with generalized estimating equations (GEE) was utilized to understand factors that impact the likelihood of embryos from a given patient being aneuploid. RESULTS: Overall, aneuploidy was detected in 47% of the embryos resulting from 1190 fresh IVF cycles in which PGS was performed. As expected, higher aneuploidy rates were observed with increased maternal age (2% with each unit increase in patient’s age (p¼0.012)). After controlling for age and FSH levels, we observed that the likelihood of aneuploid embryos decreased with greater numbers of oocytes retrieved (2% decrease in likelihood per unit increase in retrieved oocytes) (p<0.0001). Antagonist and Estrogen priming protocols were associated with increased aneuploidy rates (20% (p¼0.0016) and 23% (p¼0.02), respectively) compared to Down Regulation and MicroFlare protocols. We also observed that increasing Gn dosage was only associated with a significant increase in aneuploidy rates in patients who were stimulated past day 12 (mean surge day ¼ 12, 95% CI ¼ 10-15), with every 1000 unit increase in the cumulative Gn dosage past day 12 [mean dose ¼ 3320, 95% CI ¼ 1350 - 5550] corresponding with a 15% increase in the aneuploidy rate (p¼0.0003). CONCLUSIONS: Protocols relying on minimal or no Gn stimulation have gained traction in the US and abroad. We demonstrated that higher dosages of Gn correlate with higher numbers of oocytes retrieved, but not with increased likelihood of a resultant embryo being aneuploidy in most patients. A small increase was seen in low responding patients who received increasing dosages for more than 12 days of stimulation, but this effect may be related to the patient population and not the stimulation protocol. For most IVF patients, standard stimulation protocols do not seem to result in diminished embryo quality.
Vol. 104, No. 3, Supplement, September 2015
Autophagy induction in donor PBMCs by sera from women with different IVF outcomes
Median ng/mL p62
(range)
No rapamycin
+ rapamycin
OUTCOME Term birth Preterm birth SAB BC pregnancy Not pregnant Ectopic pregnancy
7.5 (<0.1-20.3) 9.2 (3.1-17.2) 14.8 (9.8-17.2)a 19.1 (9.2-5.4)c 9.6 (2.5-25.9) 3.6 (1.1-18.3)e
2.1 (<0.1-5.7) 1.8 (<0.1-4.3) 5.7 (2.8-13.9)b 4.2 (2.9-7.9)d 2.0 (0.5-7.4) 1.1 (<0.1-9.8)
ap ¼ 0.0005; bp <0.0001; cp ¼ 0.0001; dp <0.0001; ep ¼ 0.0441 all vs. term birth. CONCLUSIONS: Inhibition of autophagy (high p62) was greatest using day 28 sera from women whose IVF cycle ended in a SAB or BC pregnancy. Conversely, sera from women with an EP induced autophagy to the greatest extent (low p62). Rapamycin induced a higher level of autophagy (lower p62) but differences between outcomes were still evident. These observations suggest that deficient autophagy induction may contribute to defective intrauterine implantation in women undergoing IVF. The serum factor(s) responsible for this effect remains to be determined. O-159 Tuesday, October 20, 2015 11:45 AM INFLUENCE OF ANTRAL FOLLICLE COUNT (AFC) ON IVF-ET OUTCOME IS MODULATED BY AGE. A. Oppenheimer, A. Bartmann, V. Genro, J. Nassar, N. Achour-Frydman, R. Fanchin. Division of Reproductive Medicine, Hospital A. Beclere, University Paris-Sud, Clamart, France. OBJECTIVE: As the ovary ages, follicles become progressively scarce and reproductively incompetent but inter-individual variations exist in the pace of follicle loss. Follicle distribution over the various stages of follicle growth also changes with aging, culminating into an increased antral/nongrowing follicles ratio in elderly premenopausal women. Together, these physiologic features concur to explain, at least in part, why some normo-ovulating, non-PCOS women have above-average AFC despite their increasing age. On the other hand, a fraction of young women surprisingly display an under-average AFC. Whether these quantitative variations reflect oocyte competence remains controversial.To clarify this issue, we investigated whether AFC differentially influences IVF-ET outcome in elderly and young patients. DESIGN: Prospective study.
e62
ASRM Abstracts
MATERIALS AND METHODS: We studied selected youngster (26-32 years) and elderly (37-42 years) IVF-ET candidates, regularly-ovulating, devoid of PCOS, and undergoing 863 COH cycles. Prior to COH, all patients had either documented increased (20-24 follicles) or reduced (5-13 follicles) AFC (3-10 mm in diameter in both ovaries) at transvaginal ultrasound scans. According to age and AFC, patients were sorted into 4 groups as follows: Youngster-Increased AFC (n¼167), Youngster-Reduced AFC (n¼208), Elderly-Increased AFC (n¼122), and Elderly-Reduced AFC (n¼366). Clinical pregnancy and live birth rates were the outcome measures. In addition, serum AMH levels were assessed in all patients. Multivariate analysis was performed. RESULTS: Clinical pregnancy and live birth rates were similar in ElderlyIncreased (36.1% and 24.6%, respectively) or Elderly-Reduced (34.4% and 23.2%, respectively) AFC groups. Yet, in the Youngster-Increased AFC group, patients showed an improved IVF-ET outcome (55.1% and 46.7%) as compared to the Youngster-Reduced AFC (37.7% and 30.8%) group (P< 0.001 and P< 0.002, respectively). Multivariate analysis confirmed that only in young patients AFC is related to IVF-ET outcome. Similar results were obtained when using AMH instead of AFC to discriminating ovaries with good or defective follicle endowment. CONCLUSIONS: The present results indicated that, in IVF-ET candidates, the quantity of antral follicles recorded at ultrasound scans reflect the overall follicle health only in young patients (27-32 years). In elderly patients (37-42 years), even marked variations in AFC failed to influence the likelihood of live birth. These data are contributive for orientating clinical practice and raise unanswered questions on the mechanisms regulating the association between follicle quantity and quality during ovarian aging. O-160 Tuesday, October 20, 2015 12:00 PM OPTIMIZING GONADOTROPIN STIMULATION TO MAXIMIZE THE LIKELIHOOD OF OBTAINING EUPLOID EMBRYOS. J. A. Lee,a H. Karvir,b P. Yurttas Beim,c A. B. Copperman.a,d aReproductive Medicine Associates of New York, New York, NY; bCelmatix Inc., New York, NY; cCelmatix Inc, New York, NY; dObstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY. OBJECTIVE: In order to optimize the number of viable oocytes retrieved for IVF, reproductive endocrinologists alter gonadotropin (Gn) dosage and duration of simulation. The ultimate measure of a successful IVF cycle is a euploid embryo. Here we aimed to understand the relationship between commonly adjusted Gn stimulation parameters and the likelihood of obtaining euploid embryos. These insights better enable data-driven personalization of protocols for patients undergoing fertility treatments. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: Patients who underwent fresh IVF with embryo screening (pre-implantation genetic screening (PGS)) from 2009 2015 were included. Binomial regression with generalized estimating equations (GEE) was utilized to understand factors that impact the likelihood of embryos from a given patient being aneuploid. RESULTS: Overall, aneuploidy was detected in 47% of the embryos resulting from 1190 fresh IVF cycles in which PGS was performed. As expected, higher aneuploidy rates were observed with increased maternal age (2% with each unit increase in patient’s age (p¼0.012)). After controlling for age and FSH levels, we observed that the likelihood of aneuploid embryos decreased with greater numbers of oocytes retrieved (2% decrease in likelihood per unit increase in retrieved oocytes) (p<0.0001). Antagonist and Estrogen priming protocols were associated with increased aneuploidy rates (20% (p¼0.0016) and 23% (p¼0.02), respectively) compared to Down Regulation and MicroFlare protocols. We also observed that increasing Gn dosage was only associated with a significant increase in aneuploidy rates in patients who were stimulated past day 12 (mean surge day ¼ 12, 95% CI ¼ 10-15), with every 1000 unit increase in the cumulative Gn dosage past day 12 [mean dose ¼ 3320, 95% CI ¼ 1350 - 5550] corresponding with a 15% increase in the aneuploidy rate (p¼0.0003). CONCLUSIONS: Protocols relying on minimal or no Gn stimulation have gained traction in the US and abroad. We demonstrated that higher dosages of Gn correlate with higher numbers of oocytes retrieved, but not with increased likelihood of a resultant embryo being aneuploidy in most patients. A small increase was seen in low responding patients who received increasing dosages for more than 12 days of stimulation, but this effect may be related to the patient population and not the stimulation protocol. For most IVF patients, standard stimulation protocols do not seem to result in diminished embryo quality.
Vol. 104, No. 3, Supplement, September 2015