Natural IVF/ET - treatment success Neda Smiljan Severinski Marko Gospić.
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Transcript of Natural IVF/ET - treatment success Neda Smiljan Severinski Marko Gospić.
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Natural IVF/ET - treatment success
Neda Smiljan Severinski
Marko Gospić
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Terminology
• Natural IVF/ET cycleNatural IVF/ET cycle:– Monitoring of natural cycle - ultrasound– No any medication
• Modified natural cycle– Monitoring of natural cycle– Only medication is hCG injection for final
oocyte maturation
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SuccessSuccess of assisted reproduction ? of assisted reproduction ?
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How to define or calculate IVF/ET How to define or calculate IVF/ET cycle succycle succcess ?ess ?
• CLINICAL PREGNANCY CLINICAL PREGNANCY RATE (CPR):RATE (CPR):
(positive heart beat in intrauterine embryo):
• In relation to started cycle• In relation to number of oocyte
aspirations
• In relation to number of embryo transfers
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How to define or calculate IVF/ET How to define or calculate IVF/ET cycle sucess ?cycle sucess ?
• LIVEBIRTH RATE:LIVEBIRTH RATE:• In relation to started cycle• In relation to number of
oocytes aspirations• In relation to number of
embryo transfers
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What is failWhat is faileded cycle of assisted cycle of assisted reproduction ?reproduction ?
Cycle cancelation before ovum pick up ? Cycle with bad quality oocytes or without oocytes ? Oocytes fertilisation failure or irregular fertilisation ? Cycle without embryo transfer or bad quality embryos ? Cycle with implantation failure ? Cycle with positive hCG, without clinical pregnancy ? Cycle with vital clinical pregnancy but spontaneus
abortion in first trimester? . . . . .
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Absent foliculogenesisAbsent foliculogenesis and oogenesis and oogenesis
• Patients category ?Patients category ?Young reproductive age with diminished ovarian reserve or premature ovarian failureOlder reproductive age (> 35 – 40)Old reproductive age ( > 40 )
•Treatment options:Treatment options:• Natural cycle IVF/ETNatural cycle IVF/ET„Patient friendly IVF/ET”Conventional ovarian stimulationAgressive ovarian stimulation – „fight for every egg”Adjuvant drugs – androgens DHEA
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Cycle without Cycle without embryo transferembryo transfer
Bad quality of oocytes, sperm or embryosGrowth retarded embryosDisturbance in endometrium development
Other complication
• Treatment options:Treatment options:DHEA, corticosteroids, LH
Estrogen, progesteron, sildenafil
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Interpretation of treatment success?
Institutions with excellent succes of treatment : inclusion - exclusion criterias to starting treatment
Some institution have „cut off” values: age, FSH, AMH or AFC
Results of donation treatment programme:represent the real success of some institutions in
conventional IVF/ET treatment
Who are patients in the center for infertility treatment?
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Natural fecundabilityNatural fecundability
10
100
0 2 4 6 8 10 12
Months of unprotected intercourse
Per
cent
fai
led
Nulliparous
Parous
5 months
2.7 months
50
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Patients and methodsPatients and methods
• Period 1.1.2010 – 31.12.2011 ( two years )
• 89 patients (couples)
• Age: mean = 34,2 (min. = 24, max. = 45)• 181 modified natural IVF/ET cycles• mean = 2,03 cycle/patient
• only one patient had 8 natural IVF/ET cycles
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Legal aspects of treatment
• VII/2009 – VII/2012 “Restrictive” law
• Health ensurance guarantee:– No age limitation for treatment– Number of IVF/ET in natural cycle was
unlimited
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Age structureAge structureonly 36% < 33 year
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ResultsResults of treatment of treatment
Total
Number of cycles 181
Number of ET/cycles 65 (35,9%)
Pregnancy number: /cycle / ET
15(8,3%)
(23,1%)
Failed cycles 116 (64,1%)
- No oocyte- No fertilisation- No developed embryo- Growth retarded embryo- Polyploidy
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Period of treatment = 8 months = 8 modified natural cycle
0102030405060708090
100
1. 2. 3. 4. 5. 6. 7. 8.
cycle pregnancy
Treatment months
n = 89
n = 1
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Pregnancy Pregnancy n = 15/89 couples (16,8%)
0
5
10
15
20
25
30
35
1. 2. 3. 4. 5. 6. 7. 8.
ET pregnancy
Treatment months
Max 8
Min 1
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Completed cycles (n=65/181 – 35,9%)
0102030405060708090
100
1. 2. 3. 4. 5. 6. 7. 8.
cycle ET
35,5%
37,1%
38,4%29,2% 57,1%
Treatment months
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Pregnancy per cycle, overview
0
20
40
60
80
100
1. 2. 3. 4. 5. 6. 7. 8.
pregnancy % cycle
Min4,2%
Max15,4%
Month of treatment
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Pregnancy per embryotransfer, overview
83 1 2 2 0 0 00
10
20
30
40
50
1. 2. 3. 4. 5. 6. 7. 8.
pregnancy % ET
Min14,3%
Max40%
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Failed cycles
0102030405060708090
100
1. 2. 3. 4. 5. 6. 7. 8.
cycle faild
63%
64,4%70,1% 42,8%
61,5%
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Cummulative results
Month of treatment 1 2 3 4 5 6 7 8
Cumulative cycles 89 126 147 159 164 164 165 166
Cumulative pregnacies 8 11 12 14 15 15 15 15
Cumulative pregnancies %
8,98 8,73 8,16 8,88 9,14 9,14 9,09 9,03
Chance for concieving in natural IVF/ET is 8-9% in each month of treatment.After six months of treatment chance to concivewould be 54 % !!!!
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Month of treatment 1 2 3 4 5 6 7 8Theoretical number of women ( n )
89 81 78 77 75 74 74 74
Real number of women ( n )
89 45
(-36)
24
(-54)
13
(-63)
7
(-68)
1
(-73)
1
(-73)
1
(-73)
Pregnancy per month ( n )
8 3 1 2 1 0 0 0
Real cummulative pregnancies
8 11 12 14 15 15 15 15
Theoretical cummulative pregnancy ( 9%)
8 15
(+4)
22
(+10)
29
(+15)
36
(+21)
36 36 36
Monthly cummulative success %
8,98 8,73 8,16 8,88 9,14 9,14 9,09 9,03
Theoretical calculation of success: pregnancy rate
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Treatment problems
Cycle (n = 89)
0
10
20
30
40
50
60
70
80
90
100
1 2 3 4 5 6
Months of treatment
%
100%
45/89 = 50,6%
24/45 = 53,3%
13/24 = 54,2%7/13 = 53,8%
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Conclusion
• Monthly cummulative cuccess (PR/cycle) in modified natural cycles was about 9% in each month
• Significant amount of couples cancel their treatment after only three months. Why?
• Continuation and repeating of monthly treatment in modified natural cycle may have positive influence on PR
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Legal aspects of treatment
• VII/2012 – today “Liberal” law
• Health ensurance guarantee:– age limitation for treatment – 42 year– Number of IVF/ET in natural cycle is only two
– Chance to concive in modified natural cycle is 18% for each patient