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P R EMATURE OVARİAN İNSUFFİCİENCY What Does the Data Show for Pr emature Ovarian Insufficiency?

P R EMATURE OVARİAN İNSUFFİCİENCY What Does the Data Show for Pr emature Ovarian Insufficiency?. PINAR ÖZCAN,MD, PHD, Associate Professor ACIBADEM UNİVERSİTY MEDİCAL FACULTY ACIBADEM MASLAK HOSPİTAL DEPARTMENT OF OBSTETRİC&GYNECOLOGY DİVİSİON OF REPRODUCTİVE ENDOCRİNOLOGY AND INFERTİLİTY.

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P R EMATURE OVARİAN İNSUFFİCİENCY What Does the Data Show for Pr emature Ovarian Insufficiency?

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  1. PREMATURE OVARİAN İNSUFFİCİENCYWhat Does the Data Show for PrematureOvarian Insufficiency? PINAR ÖZCAN,MD, PHD, Associate Professor ACIBADEM UNİVERSİTY MEDİCAL FACULTY ACIBADEM MASLAK HOSPİTAL DEPARTMENT OF OBSTETRİC&GYNECOLOGY DİVİSİON OF REPRODUCTİVE ENDOCRİNOLOGY AND INFERTİLİTY

  2. OVARİAN RESERVE Ovarian reserve the functionalpotential of the ovary and reflects the number and quality of the remaining follicles and oocytes in both ovaries at a givenage

  3. ENVİRONMENTAL AND DEVELOPMENTAL ORİGİNS OF OVARİAN RESERVE Richardson MC, Hum Reprod Update 2014

  4. ENVİRONMENTAL AND DEVELOPMENTAL ORİGİNS OF OVARİAN RESERVE Richardson MC, Hum Reprod Update 2014

  5. ENVİRONMENTAL AND DEVELOPMENTAL ORİGİNS OF OVARİAN RESERVE Richardson MC, Hum Reprod Update 2014

  6. DESCRİPTİONKeyquestion… What should this condition be called? • Premature ovarian failure, • Primary ovarian failure, • Premature menopause, • Premature ovarian insufficiency ESHRE Guideline, Hum Reprod 2016

  7. DESCRİPTİON • Primary ovarian insufficiency (POI), a clinical syndrome, is defined by the exhaustion of the functional potential of ovariesprior to 40 years of age. • POI is characterized by menstrual disturbance (oligomenorrhea or amenorrhea), with raised gonadotrophins, low estradiol and low anti Mullerian hormone (AMH) levels ESHRE Guideline, Hum Reprod 2016

  8. What is the prevalence of POI in the generalpopulation? • The overall presumption regarding the prevalence of POF is that occurs in 1–2% of the general population

  9. METABOLİC AUTOİMMUNE ENVİRONMENTAL ETIOLOGY IDIOPATIC GENETİC INFECTİOUS IATROGENİC

  10. Diagnosis of POI • The diagnosis POI is based on the presence of menstrual disturbance andbiochemicalconfirmation. • Although proper diagnostic accuracy in POI is lacking, the GDGrecommends the following diagnostic criteria: (i) oligo/amenorrhea forat least 4 months, (ii) an elevated FSH level >25 IU/l on two occasions>4 weeks apart ESHRE Guideline, Hum Reprod 2016

  11. OBSTETRICS & GYNECOLOGY, 2014

  12. What are the known causes of POI andhow should they beinvestigated? Summary of diagnostic workup for POI ESHRE Guideline, Hum Reprod 2016

  13. Fragile X premutation in women Normal (5–44repeats), Intermediate (45–54 repeats), Premutation (55–200 repeats), Full mutation (>200 repeats) Hoyos LR, J Assist Reprod Genet 2017

  14. Lancet, 2010

  15. Qin Y, Hum Reprod, 2015

  16. Curr Obstet Gynecol Rep 2017 J North American Menopause Society, 2016

  17. JCAM, 2016

  18. Four of the following theoretical risks, infection of the endometriomas, follicular fluid contamination with the endometrioma content, higher risk of pregnancy complications and cancer development later in life. The first three conditions do not justify surgery because these events are uncommon and the number of women needed to be treated would be exceedingly high and would not justify the costs and risks of the intervention. The possibility of developing ovarian cancer later in life is more troublesome because it is a life-threatening condition, this risk can be effectively prevented by postponing surgery until after the IVF programme is concluded or when women have definitely satisfied their reproductive wishes. The available evidence on the risks of conservative management does not support systematic surgery before IVF in women with small ovarian endometriomas. Somigliana E, Human Reprod Update, 2015

  19. The objectives of these proposed strategies are: (i) first, to avoid unnecessary surgical procedures, and especially those contributing to damage ovarian reserve; and (ii) second to perform ‘the endometriosis surgery’ at the appropriate time. Ideally, patients should undergo surgical treatment only once in their ‘endometriosis life’. In particular, use of hormonal medical treatment in patients with no immediate desire to conceive (with or without infertility) allows delaying the surgical intervention at the best time. Similarly, the place of ART in the treatment sequence should be carefully considered. Currently, ART is too often proposed at the end of the ‘infertility story’ after several surgical procedures, especially for OMA management. A main objective for the future would be to identify those patients for whom there are benefits to perform ART first, before the surgery. Santilli P, Hum Reprod 2016

  20. OBSTETRICS & GYNECOLOGY, 2015

  21. There is no screening test that can be used alone toaccurately measure the residual pool of primordialfollicles and predict a woman’s reproductive lifespan.

  22. Hum Reprod 2012

  23. Sequelae of POI !!!!! What are the consequences of POI for life expectancy? Curr Obstet Gynecol Rep 2017

  24. Sequelae of POI What are the consequences of POIforlife expectancy?

  25. OBSTETRICS & GYNECOLOGY, 2017

  26. HRT is indicated for the treatment of symptoms of low estrogen in women with POI • Women should be advised that HRT may have a role in primaryprevention of diseases of the cardiovascular system and for bone protection • 17-bestradiol is preferred to ethinyl estradiol or conjugated equine estrogens for estrogen replacement • Women should be informed that whilst there may be advantages tomicronized natural progesterone, the strongest evidence of endometrialprotection is for oral cyclical combined treatment ESHRE Guideline, Hum Reprod 2016

  27. ESHRE Guideline, Hum Reprod 2016

  28. Oxıdativestress

  29. Zapardiel I, Hum Reprod Update 2016

  30. Fertil Steril 2013

  31. Fertil Steril 2014

  32. Kawamura K, Curr Opin Obstet Gynecol 2016

  33. Leng L, Hum Reprod 2015

  34. Jonathan L Tilly, nature protocols 2013

  35. Fertilitypreservation-ClinicalPracticeGuideline Fetility preservation Group for UTD guideline   Coordinator : Dr. L. Cem Demirel Dr. Pınar Özcan Dr. Volkan Turan Dr. Enis Özkaya Dr. Nuray Bozkurt Dr. L. Cem Demirel

  36. Conclusion • POI has widespread consequences for general health and fertility • To investigate for the causes of POI • Assessment of risk for POI • Fertility preservation options • HRT is indicated for the treatment of symptoms of low estrogen in women with POI at least until the average age of menopause • Women should be advised that HRT may have a role in primaryprevention of diseases of the cardiovascular system and for bone protection

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