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L9 WHAT ROLE DO ANDROGENS PLAY IN OVARIAN STIMULATION?
Abstracts, Lectures menstrual cycle has not yet been defined. However, in the hypohypo patient-defined to have an endogenous LH level <1.2 IU/I 75 IU of LH daily is sufficient to promote not only follicular growth, but also estradiol production (European r-hLH study group 1998). In contrast, Hillier (1994) proposed the concept of an “LH ceiling”, above which follicular growth is arrested. This theory has since been confirmed by pilot studies in WHO type I anovulatory patients and WHO type II patients, but it still remains to be determined whether this postulated ceiling effect has any consequences in normogonadotropic patients. Moreover, it is open to question whether this ceiling at all can be reached with the LH content of available preparations, given in generally accepted therapeutic doses. Several studies have until now addressed the effect of rec LH supplementation. The results of some of these studies indicate that 2 subgroups of normogonadotropic patients indeed seem to benefit from the addition of LH activity to the stimulation protocol: 1. Patients >35 years (Marrs et al., 2004, Humaidan et al., 2004; Bosch et al., 2008; Matorras et al., 2009) 2. Patients with an initial poor response to rFSH (Ferraretti et al., 2004; de Placido et al., 2005). Possible biological reasons for a beneficial effect of LH activity supplementation in these sub-groups will be discussed, including a hypothesis of “biological aging” of the ovary and the concept of pharmacogenetics. L6 GnRH AGONIST AND ANTAGONIST: HOW TO OPTIMIZE THEIR USE IN OVARIAN STIMULATION M. Leondires. Reproductive Medicine Associates of CT, Norwalk, USA The ability to prevent premature luteinization revolutionized ovulation induction for in vitro fertilization. By tailoring the use of GnRH-agonist and antagonist the goal is to optimize stimulation parameters, oocyte quality, endometrial receptivity, patient satisfaction and pregnancy outcomes. Protocol choice should be decided based on baseline patient characteristics and previous stimulation records when available. GnRH-agonists can be used in a long protocol format may represent the gold standard within our field. For the ovulatory young (<35) patient it remains the protocol of choice. There are concerns about their suppressive effects on follicle development and endometrial receptivity. When GnRH-agonists are used in micro doses they provide excellent protection against premature luteinization and minimize the utilization of medications. In some patients, this protocol may serve to augment with pituitary gonadotropins the initial part of the stimulation. This represents a popular protocol for patients in older age groups where concerns of ovarian reserve and maximizing egg yield predominate. GnRHantagonists present a multitude of options for use and require less total injections than either GnRH-agonist protocols. This has become a choice for the young ovulatory patients and those who are at risk of OHSS. GnRH antagonist protocols leave the provider the option for a GnRH agonist trigger protocol thereby reducing the risk of OHSS. In addition, some groups have used luteal GnRH-agonist in poor responders to prevent early recruitment of follicles in the luteal phase the cycle prior to stimulation. There remain concerns about possible negative effects on endometrial receptivity associated with GnRH-antagonist protocols. L8 OVARIAN STIMULATION IN PCOS AND HIGH RESPONDERS A. Guti´ errez. Instituto de la Ciencia de la Reproducci´ on Humana VIDA, Le´ on, Mexico Polycystic ovary syndrome (PCOS) is a heterogeneous disorder of functional androgen excess, although its definition remains con-
S9 troversial, PCOS is characterized by clinical and/or biochemical hyperandrogenism and is frequently accompanied by ovulatory dysfunction and polycystic ovaries. Up to 75% of women with PCOS suffer from infertility. The management of infertility in PCOS depends on patient characteristics and usually involves weight loss and clomiphene citrate (CC), or gonadotropin therapy for women who have failed to CC therapy. However, due to an increased sensitivity to FSH, multifollicular recruitment and hyper-response to gonadotropin therapy is the main problem. In vitro fertilization (IVF) is not the first line treatment for PCOS, but many patients with the syndrome may be referred for IVF, either because there is another reason for their infertility or because they fail to conceive despite ovulating for more than 6 months. The response of women with PCOS to IVF treatment is often different from women with normal ovaries. Significantly more oocytes are recovered per cycle in the PCOS group compared with the women with tubal factor, and in many cases are associated with lower fertilization rates. Despite the fact that they often require a lower total dose of FSH during stimulation compared with women with normal ovaries, women with PCOS are at a greater risk of developing moderate-tosevere ovarian hyperstimulation syndrome (OHSS). They also have a significantly higher incidence of cancellation of embryo transfer due to failure of fertilization and the risk of OHSS. The miscarriage rates following IVF treatment in also increased in women with PCOS. The optimal strategy for controlled ovarian stimulation (COS) is the subject of much current debate. The objective is to achieve multifollicular development, resulting in the collection of several appropriately mature oocytes, but without causing OHSS. The first approach is to decrease FSH dosage with the addition of GnRH analogs to prevent premature LH surge. GnRH-antagonist in PCOS patients has a lower incidence of OHSS with similar pregnancy and implantation rates, when compared to the long course GnRH agonist. It has been also demonstrated that co-treatment with metformin for patients with PCOS undergoing IVF/ICSI cycles significantly improves the pregnancy outcome and reduces the risk of OHSS. Although there have been attempts to predict ovarian response through endocrinologic and sonographic profiles, non successful prediction models can be generated yet. It would be very beneficial to have a method to stimulate the development of a desired number of follicles in women with PCOS. Recently, the use of circulating anti-Mullerian hormone to individualize treatment strategies for COS showed reduced clinical risk, optimized treatment and maintained pregnancy rates. Immature oocytes retrieved from antral follicles of unstimulated PCOS ovaries via transvaginal approach and subsequently matured and fertilized in vitro presents many clinical advantages with the avoidance of exogenous gonadotropins, most importantly by avoiding the risk of OHSS. In vitro maturation may be a promising alternative to conventional IVF in PCOS patients. L9 WHAT ROLE DO ANDROGENS PLAY IN OVARIAN STIMULATION? L. Devoto. Human Reproduction Division Faculty of Medicine, Hospital San Borja, University of Chile, Santiago, Chile The steroidogenic pathway within the human ovary gives rise to progestins, androgens and estrogens, all of which act via specific receptors to regulate reproductive function. Previously, no role in female reproductive physiology beyond testosterone (T) or androstenedione (A) as the precursor in estrogens biosynthesis had been firmly established. Evidence for the role of androgens arises from pharmacological observations that T, A and DHT can promote early follicular growth and enhance the FSH-mediated action. Androgens biosynthesis, which is LH-dependent, can mediate their actions directly via the androgen receptor (AR) or have an indirect effect by
S10 their conversion to estrogens and 3 beta-diol that can activate the estrogen receptor. Interestingly, AR mRNA is expressed in preantral and antral follicle theca and granulosa cells. In primates, AR mRNA expression is positively correlated with FSH receptor (FSHR) mRNA and proliferation. However, it is unclear whether this effect is AR- or ER-mediated as T, or A may have been aromatized to estradiol (E2). These pharmacological and molecular studies determined a key role of androgens in follicular growth of primordial follicles and recruitment. The present findings provide the rationale to initiate new approaches in ovulation induction treatments based in the observation that pharmacological supplementation of T-DHEA or by intraovarian accumulation of androgens by aromatase inhibitors or directly by rLH stimulated androgen secretion could improve our pharmacological approach to ovulation induction. Treatment considerations such as pharmacology, dose, safety, effectiveness, collateral effects and patient needs will be analyzed. L10 KEYNOTE LECTURE: PGD: GENETICS OR PROTEOMICS? W. Kearns. Shady Grove Center for Preimplantation Genetics, Washington, USA Preimplantation genetic diagnosis (PGD) identifies genetic abnormalities in preimplantation embryos prior to embryo transfer. PGD is an exciting technology that may improve the likelihood of a successful pregnancy and birth for five distinct patient groups: 1. those with infertility related to recurrent miscarriages or unsuccessful in vitro fertilization (IVF) cycles, 2. those with unexplained infertility, 3. advanced maternal age, 4. severe male factor infertility and 5. couples at risk for transmitting a hereditary disease to their offspring. PGD is performed following an IVF cycle where multiple oocytes are retrieved and fertilized. Sophisticated techniques such as single nucleotide polymorphism (SNP) and comparative genomic hybridization (CGH) microarrays and multi-probe, multi-color fluorescence in situ hybridization (FISH) are used to test single cells for structural or numerical chromosome abnormalities, while the polymerase chain reaction (PCR), linkage analysis and DNA sequencing are used to analyze single cells for disease specific DNA mutations. PGD allows one to transfer only those embryos identified as being free of genetic abnormalities, thus potentially increasing the implantation rate and decreasing the miscarriage rate. These technologies identify embryos free of specific genetic abnormalities and may increase the likelihood of achieving the patients’ goal: the birth of a healthy baby. This presentation will discuss cell types used for PGD and compare and contrast the different methodologies used for preimplantation genetic diagnostics. This presentation will also discuss proteomics, a non-invasive method that could be employed to more accurately “pick” the best embryo to transfer from an embryological point of view. Current embryo selection methods, that are based on oocyte/zygote/cleavage stage embryo/blastocyst morphologic assessment, are not fully able to identify the embryos with the highest implantation potential. Therefore, new embryo selection techniques are needed. Proteomics is a non-invasive methodology that measures proteins in spent media surrounding a single embryo growing in vitro. Some feel that proteomic analysis of secreted proteins shows promise as an additional tool for embryologists to assess the viability and competence of preimplantation embryos. This presentation will discuss the pros and cons of preimplantation genetic diagnostics versus proteomics.
R. Fischer L11 ENDOMETRIAL RECEPTIVITY: EVALUATION CRITERIA P. Serafini. Reproductive Health Centre Hospital das Clínicas da Universidade de S˜ ao Paulo, S˜ ao Paulo, Brazil The aim of this presentation is to discuss the methods for evaluation of uterine receptivity and their predictive value. The earliest criteria for endometrial evaluation were established by Noyes et al. in 1950 and they were based on the histological morphology of the endometrium during the menstrual cycle. Sixty years later the Noyes’ criteria are still in use for endometrial dating, but they have a limited use to foresee the endometrial receptivity to an embryo. Embryo implantation is a complex dynamic process comprising several cellular, ultrastructural and molecular mechanisms initiated and mediated by the endometrium, the embryo and by the interaction of both. To address these changes and understand the function of endometrium during the embryo implantation several researchers performed a myriad of screening investigational methods ranging from immunohistochemistry to more complex techniques of chromatography such as matrix-assisted laser desorption/ionization time of flight (MALDI-TOF). Potential markers of endometrial receptivity have been assessed by endometrial aspirate or biopsies at the third “window of implantation” (period of endometrial receptivity defined between the 19 and 23 days of the menstrual cycle). Proteins such as a3b5 integrins, leukemia inhibitor factor (LIF) and L-selectin, among others, might be used to predict success of pregnancy during natural or stimulated cycles for in vitro fertilization treatments. Additionally to the molecular methods of endometrial evaluation, sonographic exams can be performed into an outpatient facility and during routine evaluation of the patients. Evaluation of endometrial blood flow or tri-dimensional features of the endometrium might be useful to evaluate the receptivity to embryo during infertility treatments. L12 HOW TO IMPROVE ENDOMETRIAL RECEPTIVITY IN STIMULATED CYCLES M. Leondires. Reproductive Medicine Associates of CT, Norwalk, USA Endometrial receptivity remains a significant clinical question in stimulated cycles. Variables include pre-existing conditions, elevated estradiol levels, elevated progesterone levels, and the effects of medication. A better understanding of embryo apposition, implantation, and placentation is necessary to answer many of these questions. Researchers continue to struggle with the unique features of human implantation when compared to other readily available animal models. Proper evaluation of the uterus and endometrial cavity is an essential aspect of improving endometrial receptivity. Evaluation and treatment of myomas and polyps near or in the cavity is essential. Proper assessment of thickness and ultrasound characteristics may be of less importance than previously assigned. Ovarian hyperstimulation and the associated elevated estradiol and progesterone levels lead to many changes on a molecular level. In patients with recurrent implantation failure of high quality embryos, the receptivity of the endometrium must be addressed. The corpus luteum is an ovarian structure with maternal instincts and suicidal tendencies. LH has a central role in the maintenance of corpus luteum function. The corpus luteum is a unique hormone-regulated reproductive gland with transitory duration (14±2 days), produce progesterone for the establishment and maintenance of early pregnancy. On the other hand, luteal regression is incompletely understood and the evaluation of the corpus luteum “in vivo” is not free of criticisms. The frequency of pulsatile release of LH declines progressively during the luteal
S9 troversial, PCOS is characterized by clinical and/or biochemical hyperandrogenism and is frequently accompanied by ovulatory dysfunction and polycystic ovaries. Up to 75% of women with PCOS suffer from infertility. The management of infertility in PCOS depends on patient characteristics and usually involves weight loss and clomiphene citrate (CC), or gonadotropin therapy for women who have failed to CC therapy. However, due to an increased sensitivity to FSH, multifollicular recruitment and hyper-response to gonadotropin therapy is the main problem. In vitro fertilization (IVF) is not the first line treatment for PCOS, but many patients with the syndrome may be referred for IVF, either because there is another reason for their infertility or because they fail to conceive despite ovulating for more than 6 months. The response of women with PCOS to IVF treatment is often different from women with normal ovaries. Significantly more oocytes are recovered per cycle in the PCOS group compared with the women with tubal factor, and in many cases are associated with lower fertilization rates. Despite the fact that they often require a lower total dose of FSH during stimulation compared with women with normal ovaries, women with PCOS are at a greater risk of developing moderate-tosevere ovarian hyperstimulation syndrome (OHSS). They also have a significantly higher incidence of cancellation of embryo transfer due to failure of fertilization and the risk of OHSS. The miscarriage rates following IVF treatment in also increased in women with PCOS. The optimal strategy for controlled ovarian stimulation (COS) is the subject of much current debate. The objective is to achieve multifollicular development, resulting in the collection of several appropriately mature oocytes, but without causing OHSS. The first approach is to decrease FSH dosage with the addition of GnRH analogs to prevent premature LH surge. GnRH-antagonist in PCOS patients has a lower incidence of OHSS with similar pregnancy and implantation rates, when compared to the long course GnRH agonist. It has been also demonstrated that co-treatment with metformin for patients with PCOS undergoing IVF/ICSI cycles significantly improves the pregnancy outcome and reduces the risk of OHSS. Although there have been attempts to predict ovarian response through endocrinologic and sonographic profiles, non successful prediction models can be generated yet. It would be very beneficial to have a method to stimulate the development of a desired number of follicles in women with PCOS. Recently, the use of circulating anti-Mullerian hormone to individualize treatment strategies for COS showed reduced clinical risk, optimized treatment and maintained pregnancy rates. Immature oocytes retrieved from antral follicles of unstimulated PCOS ovaries via transvaginal approach and subsequently matured and fertilized in vitro presents many clinical advantages with the avoidance of exogenous gonadotropins, most importantly by avoiding the risk of OHSS. In vitro maturation may be a promising alternative to conventional IVF in PCOS patients. L9 WHAT ROLE DO ANDROGENS PLAY IN OVARIAN STIMULATION? L. Devoto. Human Reproduction Division Faculty of Medicine, Hospital San Borja, University of Chile, Santiago, Chile The steroidogenic pathway within the human ovary gives rise to progestins, androgens and estrogens, all of which act via specific receptors to regulate reproductive function. Previously, no role in female reproductive physiology beyond testosterone (T) or androstenedione (A) as the precursor in estrogens biosynthesis had been firmly established. Evidence for the role of androgens arises from pharmacological observations that T, A and DHT can promote early follicular growth and enhance the FSH-mediated action. Androgens biosynthesis, which is LH-dependent, can mediate their actions directly via the androgen receptor (AR) or have an indirect effect by
S10 their conversion to estrogens and 3 beta-diol that can activate the estrogen receptor. Interestingly, AR mRNA is expressed in preantral and antral follicle theca and granulosa cells. In primates, AR mRNA expression is positively correlated with FSH receptor (FSHR) mRNA and proliferation. However, it is unclear whether this effect is AR- or ER-mediated as T, or A may have been aromatized to estradiol (E2). These pharmacological and molecular studies determined a key role of androgens in follicular growth of primordial follicles and recruitment. The present findings provide the rationale to initiate new approaches in ovulation induction treatments based in the observation that pharmacological supplementation of T-DHEA or by intraovarian accumulation of androgens by aromatase inhibitors or directly by rLH stimulated androgen secretion could improve our pharmacological approach to ovulation induction. Treatment considerations such as pharmacology, dose, safety, effectiveness, collateral effects and patient needs will be analyzed. L10 KEYNOTE LECTURE: PGD: GENETICS OR PROTEOMICS? W. Kearns. Shady Grove Center for Preimplantation Genetics, Washington, USA Preimplantation genetic diagnosis (PGD) identifies genetic abnormalities in preimplantation embryos prior to embryo transfer. PGD is an exciting technology that may improve the likelihood of a successful pregnancy and birth for five distinct patient groups: 1. those with infertility related to recurrent miscarriages or unsuccessful in vitro fertilization (IVF) cycles, 2. those with unexplained infertility, 3. advanced maternal age, 4. severe male factor infertility and 5. couples at risk for transmitting a hereditary disease to their offspring. PGD is performed following an IVF cycle where multiple oocytes are retrieved and fertilized. Sophisticated techniques such as single nucleotide polymorphism (SNP) and comparative genomic hybridization (CGH) microarrays and multi-probe, multi-color fluorescence in situ hybridization (FISH) are used to test single cells for structural or numerical chromosome abnormalities, while the polymerase chain reaction (PCR), linkage analysis and DNA sequencing are used to analyze single cells for disease specific DNA mutations. PGD allows one to transfer only those embryos identified as being free of genetic abnormalities, thus potentially increasing the implantation rate and decreasing the miscarriage rate. These technologies identify embryos free of specific genetic abnormalities and may increase the likelihood of achieving the patients’ goal: the birth of a healthy baby. This presentation will discuss cell types used for PGD and compare and contrast the different methodologies used for preimplantation genetic diagnostics. This presentation will also discuss proteomics, a non-invasive method that could be employed to more accurately “pick” the best embryo to transfer from an embryological point of view. Current embryo selection methods, that are based on oocyte/zygote/cleavage stage embryo/blastocyst morphologic assessment, are not fully able to identify the embryos with the highest implantation potential. Therefore, new embryo selection techniques are needed. Proteomics is a non-invasive methodology that measures proteins in spent media surrounding a single embryo growing in vitro. Some feel that proteomic analysis of secreted proteins shows promise as an additional tool for embryologists to assess the viability and competence of preimplantation embryos. This presentation will discuss the pros and cons of preimplantation genetic diagnostics versus proteomics.
R. Fischer L11 ENDOMETRIAL RECEPTIVITY: EVALUATION CRITERIA P. Serafini. Reproductive Health Centre Hospital das Clínicas da Universidade de S˜ ao Paulo, S˜ ao Paulo, Brazil The aim of this presentation is to discuss the methods for evaluation of uterine receptivity and their predictive value. The earliest criteria for endometrial evaluation were established by Noyes et al. in 1950 and they were based on the histological morphology of the endometrium during the menstrual cycle. Sixty years later the Noyes’ criteria are still in use for endometrial dating, but they have a limited use to foresee the endometrial receptivity to an embryo. Embryo implantation is a complex dynamic process comprising several cellular, ultrastructural and molecular mechanisms initiated and mediated by the endometrium, the embryo and by the interaction of both. To address these changes and understand the function of endometrium during the embryo implantation several researchers performed a myriad of screening investigational methods ranging from immunohistochemistry to more complex techniques of chromatography such as matrix-assisted laser desorption/ionization time of flight (MALDI-TOF). Potential markers of endometrial receptivity have been assessed by endometrial aspirate or biopsies at the third “window of implantation” (period of endometrial receptivity defined between the 19 and 23 days of the menstrual cycle). Proteins such as a3b5 integrins, leukemia inhibitor factor (LIF) and L-selectin, among others, might be used to predict success of pregnancy during natural or stimulated cycles for in vitro fertilization treatments. Additionally to the molecular methods of endometrial evaluation, sonographic exams can be performed into an outpatient facility and during routine evaluation of the patients. Evaluation of endometrial blood flow or tri-dimensional features of the endometrium might be useful to evaluate the receptivity to embryo during infertility treatments. L12 HOW TO IMPROVE ENDOMETRIAL RECEPTIVITY IN STIMULATED CYCLES M. Leondires. Reproductive Medicine Associates of CT, Norwalk, USA Endometrial receptivity remains a significant clinical question in stimulated cycles. Variables include pre-existing conditions, elevated estradiol levels, elevated progesterone levels, and the effects of medication. A better understanding of embryo apposition, implantation, and placentation is necessary to answer many of these questions. Researchers continue to struggle with the unique features of human implantation when compared to other readily available animal models. Proper evaluation of the uterus and endometrial cavity is an essential aspect of improving endometrial receptivity. Evaluation and treatment of myomas and polyps near or in the cavity is essential. Proper assessment of thickness and ultrasound characteristics may be of less importance than previously assigned. Ovarian hyperstimulation and the associated elevated estradiol and progesterone levels lead to many changes on a molecular level. In patients with recurrent implantation failure of high quality embryos, the receptivity of the endometrium must be addressed. The corpus luteum is an ovarian structure with maternal instincts and suicidal tendencies. LH has a central role in the maintenance of corpus luteum function. The corpus luteum is a unique hormone-regulated reproductive gland with transitory duration (14±2 days), produce progesterone for the establishment and maintenance of early pregnancy. On the other hand, luteal regression is incompletely understood and the evaluation of the corpus luteum “in vivo” is not free of criticisms. The frequency of pulsatile release of LH declines progressively during the luteal