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 Freeze-All Policy: Fresh vs. Frozen-Thawed embryo transfer in PCOS patients  Freeze-All Policy: Fresh vs. Frozen-Thawed embryo transfer in PCOS patients

Freeze-All Policy: Fresh vs. Frozen-Thawed embryo transfer in PCOS patients - PowerPoint Presentation

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Freeze-All Policy: Fresh vs. Frozen-Thawed embryo transfer in PCOS patients - PPT Presentation

Jane Nani MD November 17 2015 PCOS most common endocrinopathy in women of reproductive age Bilaterally Enlarged Ovaries PCOS and IVF Exaggerated response to Ovulation induction Overt Ovarian Enlargement ID: 776635

ohss pcos hcg eggs ohss pcos hcg eggs trigger fresh taps culdocentesis frozen patients range criteria severe amp follicles

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Presentation Transcript

Slide1

Freeze-All Policy: Fresh vs. Frozen-Thawed embryo transfer in PCOS patients

Jane

Nani

, M.D.

November 17, 2015

Slide2

PCOS: most common endocrinopathy in women of reproductive age.

Slide3

Bilaterally Enlarged Ovaries

Slide4

PCOS and IVF

Exaggerated response toOvulation induction

Slide5

Overt Ovarian Enlargement

Slide6

Hyperstimulation Syndrome

Slide7

PCOS and OHSS

PCO patients are inherently at risk of OHSSEarly OHSS -Late OHSS – Early: pre-ovulatory response to gonadotropins Late: occurrence of pregnancy – more severe Mathur RS, et al., F&S (2000 May)

Egg Yield

Slide8

OHSS Strategies

Prevention!!

Slide9

Prevention Strategies

Cycle cancellation

Coasting

Pellicer

A, Hum

Reprod

(2014 Jul)

GnRH

agonist trigger

Manzanares

MA , et al., F&S, (2010 Mar)

Metformin

Palomba

S, et al,. BJOG (2013 Feb)

Cabergoline

Guvedag

ES, et al.,

Gyne

Endo (2013 Aug)

Albumin infusion

Chen CD, et al., F&S (1997 Aug)

Slide10

FCI: Policy for Freeze-All vs. Cycle cancellation

Standards for patient using HCGE2: 5000-6000If < 35 eggs, auto. Day 5 ETIf > 35 eggs retrieved, FA If E2 > 6000, cancel

Standards for pts. using

Lupron

If < 35 follicles, and E2 < 7500,

ok to proceed with ET, per MD

If E2 > 7500, cancel

IF 50 or more follicles, cancel

Slide11

IVF: 1/2014- 8/2015.

346 PCOS pts

Defined by Rotterdam criteria

Ages: range 22-43

Average Age: 32.9 yrs.

BMI: range 19-49

Average BMI: 28.2

Range In egg number: 6-60

Average number of eggs: 21

22 had more than one retrieval

Slide12

PCOS Diagnosis

Rotterdam (2003) Diagnostic criteria for PCOS- two out of three o

f

:

Clinical

Hyperandrogenism

(

Ferriman-Gallwey

Score >8) or Biochemical

Hyperandrogenism

(Elevated Total/Free Testosterone)

OR

Oligomenorrhea

(Less Than 6-9 Menses per Year) or

Oligo

-Ovulation

OR

Polycystic Ovaries on Ultrasound (>= 12

Antral

Follicles in One Ovary or Ovarian Volume >= 10 cm3)

Slide13

Ovulation Triggers

HCG: 172

Ovidrel

: 53

Lupron

: 86

Lupron

+ HCG: 55

Ovidrel

+ HCG: 2

TOTAL: 368

Slide14

Severe OHSS: Culdocentesis

14 PCOS patients met criteria for severe OHSS

All required

culdocentesis

for symptomatic relief

8 required more than one

culdocentesis

1 had 5 taps

1 had 4 taps

2 had 2 taps

6 had single taps

4 had 3 taps each

Slide15

Culdocentesis

Slide16

OHSS Patients : 3 Taps

H.P.: 55 eggs retrievedFA cycleLupron + HCG trigger N.S.: 20 eggs retrievedFresh ETPositive HCGLive birthHCG trigger

3

. R.T.:

24 eggs retrieved

FA cycle

HCG trigger

4. D.M.:

21 eggs retrieved

Fresh ET

HCG trigger

Ongoing pregnancy

Slide17

Outcomes

Fresh: PR/TR: 129/225 = 57.3% (CI: 0.508 to 0.636) / 3.5% OHSS

Frozen: PR/TR: 84/121 = 69.4% (CI: 0.607 to 0.769) / 0.5% OHSS

Difference between OHSS rates: non-significant: p = 0.572

Combined Fresh + Frozen = 213/346 = 62% (CI: 0.563 to 0.665)

Difference between Fresh

vs

Frozen: Statistically significant: p=0.028*

(Fisher’s Exact test/2 tailed p-value)

Slide18

Conclusions

PCOS pts are at risk for OHSS with COH

Avoidance of ET does not eliminate OHSS

Avoid HCG trigger

FET results exceed fresh ET

Slide19

Collaborators

Angeline N. Beltsos, MDEve C. Feinberg, MDJennifer Hirshfeld-Cytron, MDLaurence A. Jacobs, MDBrian R. Kaplan, MDEdward L. Marut, MDJohn J. Rapisarda, MDAllison K. Rogers, MDChristopher S. Sipe, MDMeike L. Uhler, MD

Sue Jasulaitis: clinical research

Embryology:

Juergen

Liebermann

Eliss

Pelt

Rebecca

Brohammer

Sara Sanchez

Yuri Wagner

Slide20

Thank You