Factors influencing IVF outcomes

1
Factors influencing IVF outcomes
Peking University Third Hospital Qiao Jie
2
Factors Affecting Conception

• Production of healthy sperm
• Healthy eggs by the woman
• Unblocked fallopian tubes
• The ability for the sperm to fertilize the egg
• The ability for the embryo to implant in the
  uterus

3
IVF success rate

• Despite the progress in IVF, people undertaking
  IVF often face a considerable risk of failure.
• -- Pregnancy rate per transfer remained 30-35
  in 2006.
• -- Delivery rate by OPU was 15-30 in fresh
  cycle in 2005.
• 
  Data from ESHRE

4
Factors affecting IVF results

• Age
• Causes of infertility
• Responsiveness to ovulation induction
• Different stimulation protocols
• Embryo quality
• Sperm quality
• Embryo transfer
• technique
• Luteal phase support

5
Factors affecting IVF results

• Age
• Causes of infertility
• Responsiveness to ovulation induction
• Different stimulation protocols
• Embryo quality
• Sperm quality
• Embryo transfer
• technique
• Luteal phase support

6
Endometriosis and IVF

• Lower pregnancy rates
• (Barnhart et al.,
  2002, P.Kuivasaari et al.2005, De Hondt A, et
  al,2005 Azem F et al,1999)
• Reduced fertilization rate
• (Bergendal et al. 1998, Azem et al., 1999,
  Yamashita Y, et al,2002, Al-Fadhli R, et al,2006
  Barnhart K, et al,2002 )
• Decreased implantation rates
• (Azem et al., 1999
  Barnhartet al., 2002 Kuivasaari et al., 2005
  Kumbak B et al,2008)
• A lower number of oocytes retrieved
• (Bergendal et al. 1998, Azem et
  al., 1999, Suzuki T, et al,2005 Kumbak B et
  al,2008 Barnhart K, et al,2002 Nakahara K et
  al, 1998)
• A lower ovarian response to gonadotrophins
• (Azem et al,1999Al-Azemi et al,2000
  Aboulghar,2003Barnhart et al,2002Kuivasaari et
  al,2005Al-Fadhli R,et al,2006 Kumbak B et
  al,2008)

7
Endometriosis and IVF

• Poor embryo quality
• (Barnhartet al., 2002
  Kuivasaari et al., 2005 Kumbak B et al,2008)
• Higher rate of early pregnancy loss
• 
  (Yanushpolsky EH et al,1998)
• Reduced birth rate per cycle
• 
  
  (Azem F et al,1999)
• Pregnancy rates for women with severe
  endometriosis were significantly lower than for
  women with mild disease
• 
  (Barnhart K, et al,2002 )

8
Endometriosis and IVF

• Lower VEGF gene expression in granulosa cells may
  adversely affect oocyte development and
  maturation
• 
  (Yamashita Y, et al,2002)
• Altered folliculogenesis
• 
  (Tummon IS,et al,1988)
• Embryo toxicity
• 
  (Damewood MD et al,1990 Simon C et al,1992)
• Increased apoptosis in granulosa cells
• 
  (Nakahara K et al, 1998)

9
Endometriosis and IVF

• Decreased expression of biomarkers of
  implantation
• -- decreased expression of HOXA10
• (Wei
  Q et al,2009 Taylor HS et al, 1999Browne H et
  al, 2006)
• -- decreased expression of glycodelin A
• 
  (Kao LC,2003 Wei Q et al,2009 Burney RO et
  al,2007)
• -- decreased expression of osteopontin
• 
  
  (Burney RO et al,2007 Wei Q et al,2009)
• -- decreased expression of lysophosphatidic acid
  receptor 3
• 
  (Wei Q et
  al,2009)
• -- decreased expression of integrin
• (Lessey BA et al,1994 Khorram O et al,2002)
• Alterations in endometrial apoptosis
• 
  (Gebel HM et al,1998 Bergqvist A et
  al,1993)

10
Hydrosalpinx and IVF

• Reduced clinical pregnancy rate
• (Sims et al.1993
  Vejtorp et al,1995Katz et al,1996 Andersen et
  al,1994 Zeyneloglu HB et al,1998 )
• Higher miscarriage rate
• (Sims et al.1993
  Strandell et al,1994 Andersen et al,1994
  Zeyneloglu HB et al,1998 )
• Lower ongoing pregnancy rate
• 
  
  (Sims et al,1993)

11
Hydrosalpinx and IVF

• Reduced implantation rate
• (Strandell
  et al,1994 Katz et al,1996 Andersen et al,1994
  Freeman et al,1996 Zeyneloglu HB et al,1998 )
• Fewer blastocysts developing
• 
  
  (Freeman et al,1996)
• Improved pregnancy, implantation and delivery
  rates after salpingectomy for hydrosalpinges
  before IVF
• (Strandell A, et al 2001 Johnson NP.et al, 2002
  Fleming and Hull 1996Murray DL,et al,1998
  Johnson et al., 2004)

12
Hydrosalpinx and IVF

• Hydrosalpinx fluid may contain cytokines,
  prostaglandins or other inflammatory compounds.
  These compounds may have either direct
  embryo-toxicity or adversely affect the
  endometrium.
• (Meyer et al., 1997)
• Simple mechanical flushing of embryos from the
  uterine cavity.
• (Mansour RT, et al, 1991)

13
Hydrosalpinx and IVF

• Embryotoxic effects
• -- lower rate of of the embryos reaching the
• morula stage and the blastocyst stage
• (Schenk et al. 1996 Sachdev R,Et
  al,1997 Koong MK,et al,1998)
• -- higher fragmentation and degeneration
  rate
• of the embryos
• (Schenk
  et al. 1996 Mukherjee T.et al,1996)
• -- poor cavitation rates
• (Mukherjee T. et al. 1996)
• -- retardation of mouse embryo development
• 
  (Beyler et al,1996 Mukherjee T.et al,1996)

14
Hydrosalpinx and IVF

• Reduce endometrial receptivity
• -- lower levels of integrins aVß3 in the
  endometrium
• 
  (Lessey et al. 1994 Meyer W et al,1997)
• -- diminished expression of HOXA10 in the
  endometrium
• 
  (Daftary GS et al, 2002 Daftary GS et
  al, 2007)
• -- reduced LIF level in the endometrium
• 
  (Seli E et al,2005)
• --increase of integrin aVß3 expression
  after surgical
• correction of hydrosalpinx
• 
  (Meyer
  W et al,1997)

15
Hydrosalpinx and IVF

• Changes in endometrial pattern and endometrial
  blood flow
• -- patients with hydrosalpinx had a
  significantly higher proportion of the
  non-multilayered endometrial pattern and
  significantly lower endometrial and
  subendometrial blood flows

Ng EHY. et al, 2006
16
Intra-ovarian Factors in Polycystic Ovary
Syndrome (PCOS) Impact on Oocyte Maturation and
Embryo Developmental Competence
17
PCOS patients typical characterization In IVF

• Increased number of oocytes
• Lower fertilization, cleavage rates
• Lower implantation rates
• Higher miscarriage rates
• Poor quality of oocytes and embryos

Human Reproduction Update, Vol.12, No.1 pp.
1321, 2006
18
PCOS

• during folliculogenesis and follicle maturation
• abnormal endocrine/paracrine factors
• metabolic dysfunction
• intrafollicular microenvironment alterations
• Impaired oocyte maturation and embryonic
  developmental competence

Seminar Reprod Med 2008 2653-61
19
Transforming growth factors (TGF-ß)

• Anti-Müllerian hormone (AMH)
• Growth differentiation factor (GDF9)
• Inhibins
• Activitins
• Bone morphological protein-15 (BMP15)

20
TGF-ßAMH
serum AMH levels reduces throughout reproductive
life
Serum AMH levels stable throughout the menstrual
cycle
Human Reproduction Update, Vol.16, No.2 pp.
113130, 2010
21
Mean AMH serum levels

• significantly higher in PCOS patients
• associated with increased development of antral
  follicles and follicular arrest in PCOS patients
• lower in POF patients

Trends in Endocrinology and Metabolism Vol.19 No.9
22
PCOS-IVFAMH

• PCOS patients
• higher levels of follicular MIS
• follicular MIS level correlating with a greater
  number of immature oocytes retrieved

Fertil Steril. 1997 May67(5)962-5
23

• PCOS in IVF Serum and FF AMH significantly
  higher
• The AMH levels significantly lower patients who
  began a pregnancy
• 
  (22.0 vs. 50.5 pMol/L, P0.018)
• a negative link between AMH and final oocyte
  maturation,possibly because of impaired access of
  FSH to follicles

Fertil Steril. 2010 Jun94(1)198-204
24
TGF-ßInhibins

• Inhibins
• produced by the dominant follicle
• stimulate theca cell androgen production for E2
  synthesis
• In IVF patients,higher FF inhibin A and B
  levels(measured on the day of oocyte retrieval)
• better oocyte maturity and fertilization rates
• higher pregnancy rates

Europ J Obstet Gynecol Reprod Biol 2004 115
194199
25
PCOSInhibins

• FF inhibin A and inhibin B concentrations are
  significantly reduced in PCOS compared with those
  in size-matched follicles from normal women
  (J Clin Endocrinol Metab.
  2005 Oct90(10)5582-7)
• 
  
• FF inhibin B levels are significantly correlated
  to embryo quality

(Hum Reprod. 2002 Jul17(7)1724-8 )
26
TGF-ßGDF 9

• GDF9, an oocyte-secreted factor
• promotes granulosa cell proliferation and
  preantral follicle growth
• its deficiency impairs granulosa cell
  proliferation and causes follicular arrest at the
  primary follicle stage

Semin Reprod Med. 2008 January 26(1) 5361
27
PCOSGDF 9

• PCOS oocytes GDF9 mRNA levels reduced
• Impaired follicle growth
• Lead to premature luteinization
• Decrease luteal generation
• Maybe altered granulosa cell-oocyte signaling

J Clin Endocrinol Metab 2002871337-1344
28
Insulin-like growth factors

• multifunctional polypeptides with insulin-like
  activity
• two receptor ligands (IGF-I and IGF-II)
• two surface-receptors (IGF1R and IGF2R)
• six high-affinity IGF binding proteins (IGFBP
  1-6)
• PCOS
• IGF-I levels in immature follicles is decreased
• IGF-II and IGFBP-1 levels lower
• lower IGFBP-1 leading to follicular arrest

Expert Rev Endocrinol Metab 2007 2(2)215-223
29
IGF

• serum and follicular fluid
• IGF-I/IGFBP-1 higher in women who became
  pregnant
• The ratio IGF-I/IGFBP-1 may reflect oocyte quality

J Assist Reprod Genet 2003 20167-176
30
PCOSIGF
PCOS patients Mean serum IGF-I and IGFBP-3
levels increased during stimulation

• Serum IGFBP-3 levels increase
• greater pregnant (P.03)
• ongoing pregnancy (P.02)

• Serum IGF-I levels decreased
• higher mean number of immature
• oocytes retrieved
• (4.81.1 vs. 2.40.4 P.02)

• IGF-I plays a key role in oocyte maturation in
  PCOS patients
• Alterations in IGFBP-3 concentration during
  stimulation may be a critical mechanism in
  modulating IGF-I activity

Fertil Steril 20078813944
31
Cytokine Family

• a large family of soluble polypeptide regulators
• interleukins (IL135)
• Leukemia Inhibitory Factor (LIF)
• Tumor necrosis factor-alpha (TNFa)
• Soluble Fas (sFas)
• Soluble Fas ligand (sFasL)
• regulating ovarian function
• exerting an influence on proliferation,
  differentiation, follicular maturation,
  steroidogenesis and apoptosis

Best Practice and Res Clinical Obste and
Gynaecology. 2004 18755-771
32
PCOS undergoing IVF

• 1) higher serum and FF interleukin-6 and TNF-a
• 2) cytokine concentrations FF gtserum
• 3) FF TNF-a concentrations were inversely
  correlated to the estradiol levels,indicative
  poor quality oocytes and embryos

Obstet Gynecol 2003 1011177 82
33
CKTNFa

• Exposure of porcine oocytes to an elevated TNF-a
  
• a reduction in their maturation from GV stage to
  MII stage
• increased the proportion of oocytes with abnormal
  
• chromosome alignment and cytoskeleton structure

Fertil Steril 2010939206

• PCOS patients treated with pioglitazone during
  COS
• FF TNF-a and IL-6 levels significantly lower
• The clinical pregnancy rate higher

Fert Steril 2009 92(suppl) s104-105
34
CKLIF

• LIF enhances embryonic development and increases
  blastocyst formation,decreasing the rate of
  embryo degeneration
• FF concentrations of PCOS during IVF

PCOS Control Donor P
LIF(pg/ml) 265 816 749 lt0.001

• The LH/FSH ratio negatively correlated with LIF
• PCOS Implatation rates lower
• FF LIF appears to function as an embryotrophic
  agent

Hum Reprod. 2001 Oct16(10)2073-8
35
CKFas FasL

• sFas and sFasL ,anti-and pro-apoptotic factors,
  respectively

• PCOS in IVF
• serum sFas ?
• treated with metformin
• serum sFas ?
• FF sFasL ?
• reduce GC DNA fragmentation
• increase implantation and clinical pregnancy rates

Hum Reprod. 2005 Sep20(9)2391-5
36
Homocysteine(Hcy)

• a homologue of the amino acid cysteine
• recycled into methionine or converted into
  cysteine in the presence of B-vitamins
• serum and FF homocysteine levels elevated are
  inversely associated with oocyte and embryo
  quality

Hum Reprod 2006 2117251733
37
PCOSHcy

• 52 PCOS patients underwent GnRHagonist / r-FSH
  treatment

• higher FF Hcy group
• Grade 3 oocyte?
• Grade 12 embryo?
• fertilization rate?

Hum Reprod. 2009 Sep24(9)2293-302
38

• multiple linear regression analyses FF Hcy is an
  independent determinant of oocyte quality and
  embryo quality

Hum Reprod. 2009 Sep24(9)2293-302
39
PCOS pregnance after IVF or ICSI

• FF Hcy levels negatively associated with FF E2
• The E2-enriched follicular fluid positively
  correlated with oocyte fertilization, cleavage
  and implantation
• higher follicular fluid Hcy levels may suppress
  E2 production and interfere with the development
  of dominant follicles,oocyte maturation and
  fertilization in women with PCOS undergoing
  assisted reproduction

Hum Reprod. 2009 Sep24(9)2293-302
40
Leptin

• 16kDa protein hormone
• regulating energy intake, energy expenditure,
  and their balance
• high FF and serum leptin levels closely
  associated with decreased oocyte maturity, poor
  fertilization and embryo quality, and lower
  pregnancy rates

Reproduction 2005 130 917921
41
PCOS undergoing ARTLeptin
variable ART success ART failure smokers PCOS
Age 34.1 35.0 34.7 31.5
Serum oestradiol(pg/ml) 1456.3 1639.6 1344.2 1781.0
Oocytes retrieved(n) 11.1 10.5 11.8 16.8
FF leptin(ng/ml) 11.94 17.00 17.23 20.87
Serum leptin(ng/ml) 16.46 19.03 22.24 31.79

• ART success group low FF and serum leptin
• PCOS group higher FF and serum leptin
• elevated leptin levels may block E2 production,
  disturbing follicular development and oocyte
  maturation

Hum Reprod. 2000 Mar15(3)539-44
42
VEGF and FGF

• Vascular endothelial growth factor (VEGF)
• a homodimeric glycoprotein
• angiogenesis, follicular vascularization and
  intrafollicular oxygenation
• Fibroblast growth factors (FGF)
• A group of polypeptides
• play a fundamental role in development, cell
  growth, tissue, regulator of FSH action

Human Reproduction 2005 20, 15621568
Expert Rev Endocrinol Metab 2007 2(2)215-223
43

• PCOS patients undergoing IVF
• serum and follicular fluid VEGF and bFGF levels

Gynecol Endocrinol. 2006 Aug22(8)465- 70
44
PCOSFGF

• bFGF seems to be an FSH-dependent growth factor

• follicular fluid bFGF levels inversely
  correlated with the percentage of mature oocytes
  collected (p0.034)

Gynecol Endocrinol. 2006 Aug22(8)465- 70
45
PCOS undergoing ICSI using a GnRH antagonist or a
GnRH agonist protocol

• between the GnRH antagonist and the GnRH agonist
• MII oocytes VEGF concentrations statistically
  significant
• (log 3.20 0.21 versus 3.34 0.15, corresponding
  mean VEGF 1774 and 2316 pg/ml, respectively) (P lt
  0.001)

Reprod Biomed Online. 2009 Jan18(1)21
46
PCOS undergoing ICSI using a GnRH antagonist or a
GnRH agonist protocol

• higher oestradiol concentrations were related to
  embryos of higher quality (P 0.037)
• PCOS GnRH antagonists decrease follicular
  oestradiol and VEGF concentrations and the number
  of retrieved MII oocytes

Reprod Biomed Online. 2009 Jan18(1)21
47
Conclusions

• Age
• Causes of infertility
• Responsiveness to ovulation induction
• Different stimulation protocols
• Embryo quality
• Sperm quality
• Embryo transfer technique
• Luteal phase support

48
Thank you for attention