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IVM is ready as a treatment for PCOS patients

IVM is ready as a treatment for PCOS patients. Dr. Milton Leong MDCM DSc (McGill) Director, IVF Center , HKSH Adjunct Professor, OBS-GYN, McGill University. PCOS. Commonest endocrine disorder in women May be 80% anovulatory infertility? Ovulation induction required

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IVM is ready as a treatment for PCOS patients

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  1. IVM is ready as a treatment for PCOS patients Dr. Milton Leong MDCM DSc (McGill) Director, IVF Center, HKSH Adjunct Professor, OBS-GYN, McGill University

  2. PCOS • Commonest endocrine disorder in women • May be 80% anovulatory infertility? • Ovulation induction required • Most are clomiphene responsive • Cumulative pregnancy rates lower than non-PCOS patients • Balen 2002 2004

  3. PCOS • Ovulation Induction: • Low dose - reduced response • Higher dose - over-response • Leading to multiple pregnancies • Higher risk OHSS

  4. PCOS and IVF • IVF is an effective, may be preferred choice of therapy because of the problems associated with ovulation induction • Significantly more oocytes • Lower fertilization rate • Dor et al, Homburg et al Kodama et al

  5. PCOS and IVF • Pregnancies were comparable to non-PCOS patients • Increased miscarriage rate • FSH requirement leads to under or over response • Higher cancellation rate • Much higher chance of OHSS

  6. PCOS, OHSS and IVF • Risk up 5-30 fold (6-30%) • Estradiol >3000pg/ml • # Follicles >20

  7. 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

  8. 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).

  9. 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 (esp br ca) can treat anytime

  10. IVM/IVF vs IVF for PCOS Child TJ, et al,2002

  11. IVM-IVF in POS 210 cycles 1883 oocytes 56% maturation 83% fertilization Pregnancy rate 31% fresh 32% frozen-thawed 50/56 pregnancies delivered Miscarriage 11% OHSS 0% A. Fukuda et al, Fertility & Sterility 2008

  12. Ovulation trigger LH surge induced by GnRH agonist achieves identical clinical outcome as HCG in in vitro maturation, in vitro fertilization and embryo transfer (IVM-IVF)

  13. GnRHav.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

  14. 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

  15. Known live deliveries from IVM/IVF

  16. McGill IVM results by age group (own oocytes only – patients with PCO or PCOS)

  17. Results of IVM from Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan* Cycles 68 Age 31.3 ± 4.1 No. of oocytes collected 1,528 (21.9 ± 9.4) % of oocyte maturation 72.5% % of fertilization 75.8% % of cleavage 89.4% Mean of embryos transferred 3.8 ± 0.9 No. of clinical pregnancies (%) 23 (33.8) % of implantation 11.3% % of OHSS <1% * Data from Dr. Lin & Dr. Hwang (2003)

  18. IVM/IVF in PCOS Conclusions: PCOS is associated with OHSS OHSS = 80% post EC hospital admissions IVM/IVF is an established clinical technique IVM/IVF can reduce incidence of OHSS IVM/IVF can now be the treatment of choice for PCOS in IVF

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