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
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Slide1
Freeze-All Policy: Fresh vs. Frozen-Thawed embryo transfer in PCOS patients
Jane
Nani
, M.D.
November 17, 2015
Slide2PCOS: most common endocrinopathy in women of reproductive age.
Slide3Bilaterally Enlarged Ovaries
Slide4PCOS and IVF
Exaggerated response toOvulation induction
Slide5Overt Ovarian Enlargement
Slide6Hyperstimulation Syndrome
Slide7PCOS 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
Slide8OHSS Strategies
Prevention!!
Slide9Prevention 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)
Slide10FCI: 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
Slide11IVF: 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
Slide12PCOS 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)
Slide13Ovulation Triggers
HCG: 172
Ovidrel
: 53
Lupron
: 86
Lupron
+ HCG: 55
Ovidrel
+ HCG: 2
TOTAL: 368
Slide14Severe 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
Slide15Culdocentesis
Slide16OHSS 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
Slide17Outcomes
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)
Slide18Conclusions
PCOS pts are at risk for OHSS with COH
Avoidance of ET does not eliminate OHSS
Avoid HCG trigger
FET results exceed fresh ET
Slide19Collaborators
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
Slide20Thank You