Principles and practices in individualizing in ART
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This document discusses principles and practices of individualization in ART (assisted reproductive technology). It emphasizes that individualizing treatment can maximize benefits, minimize risks and complications, and improve patient-centeredness. It discusses how to individualize controlled ovarian stimulation protocols based on patient characteristics and ovarian biomarkers like AMH and AFC to improve effectiveness, safety, and patient experience. Specifically, it suggests individualizing protocols for high responders, normal responders, and poor responders to balance these quality dimensions.
Principles and practices in individualizing in ART
- 1. Principles and Prac-ces of Individualiza-on in ART UAE Reproductive Symposium 2015 - Dubai Sandro C. Esteves, MD., PhD. Medical Director, ANDROFERT Andrology & Human Reproduc=on Clinic Campinas, BRAZIL
- 2. Learning Objec-ves 1. Individualiza-on: a quality concept 2. How to individualize COS to different pa-ent subgroups 3. How to individualize triggering 4. How to individualize luteal support ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 2 2015 ANDROFERT
- 3. Why individualize? ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 3 2015 ANDROFERT
- 4. Maximize beneficial effects of treatment Minimize complica-ons and risks Why individualize? ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 4 2015 ANDROFERT
- 5. Top 3 clinical dimensions for quality improvement in infer-lity care • Effec-veness: Technical aspects to deliver the best possible outcome (e.g. pregnancy, live birth, cumula=ve LBR) • Safety: Complica=ons (OHSS), adverse effects, risks (pa=ent & offspring), errors/mistakes • Pa-ent-‐centeredness: Informa=on and pa=ent involvement, competence and aPen=on of clinic and staff, accessibility, coordina=on and integra=on, emo=onal support ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 5 2015 ANDROFERT Dancet et al. Hum Reprod 2011; Mainz Int J Qual Health Care 2013
- 6. How stakeholders value the top 3 quality dimensions of infer-lity care ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 6 2015 ANDROFERT 0% 50% 100% Doctors & embryologists Nurses Pa-ents Safety Effec-veness Pa-ent-‐ centeredness Dancet et al. Hum Reprod 2013
- 7. Lack of psychological support and poor quality of service ~60% treatment discon-nua-on ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 7 2015 ANDROFERT 22 studies 21,453 pa=ents 8 countries
- 8. Individualiza-on is a quality concept ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 8 2015 ANDROFERT Safety Pa-ent-‐ centeredness Effec-veness
- 9. How to individualize? ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 9 2015 ANDROFERT
- 10. Individualizing S-mula-on Protocols ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 10 2015 ANDROFERT • Clinical characteris-cs • Ovarian biomarkers Iden-fy who is who • Pa-ent-‐centered • Effec-ve • Safe Protocol
- 11. What biomarker do you value more? a. Basal FSH b. AMH c. AFC d. Age
- 12. AMH ~ AFC > FSH > Age ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 12 2015 ANDROFERT
- 13. Popula-on Cutoff Sensi-vity Specificity Accuracy AMH ng/mL High-‐ responder1 2.1 85% 79% 0.82 Poor responder2 0.82 76% 86% 0.88 *Beckman-‐Couter genera-on II assay; 1>20 oocytes retrieved; 2≤4 oocytes retrieved Leão RBF, Nakano FY, Esteves SC. Fer5l Steril 2013; 100 (Suppl.): S16 AMH & AFC should be internally validated ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 13 2015 ANDROFERT
- 14. Quality-‐based individualiza-on in COS ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 14 2015 ANDROFERT High responders* Normal responders* Low responders* Biomarkers Safety Pa-ent-‐ centeredness Effec-veness *expected
- 15. High responders ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 15 2015 ANDROFERT • Main goal: Safety • Clinical quality indicator: OHSS • Protocol of choice*: Antagonist (flexible; cetrorelix) Tailored recFSH (112.5-‐150 IU/d; follitropin alfa; pen injector) *Androfert, Brazil
- 16. GnRH antagonists in high responders ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 16 2015 ANDROFERT 9 RCT; 966 PCO women Rela-ve Risk Dura-on of ovarian s-mula-on -‐0.74 (95% CI -‐1.12; -‐0.36) Gonadotropin dose -‐0.28 (95% CI -‐0.43; -‐0.13) Oocytes retrieved 0.01 (95% CI -‐0.24-‐0.26) Risk of OHSS Mild Moderate and Severe 20% vs 32% 1.23 (95% CI 0.67-‐2.26) 0.59 (95% CI 0.45-‐0.76) Clinical PR 1.01 (95% CI 0.88; 1.15) Miscarriage rate 0.79 (95% CI 0.49; 1.28) Pundir J et al. RBM Online 2012; 24:6-22
- 17. iCOS (n=118): rec-‐hFSH 112.5-‐150 IU + GnRH antagonist (flexible) cCOS (n=131): rec-‐FSH 150-‐225 IU + GnRH agonist (nafarelin) 39.3 18.5 14.0 57.0 14.3 14.7 4.8 56.0 0 10 20 30 40 50 60 Observed Excessive Response (%) Oocytes retrieved (N) OHSS (%) Pregnancy (%) cCOS iCOS *p<0.05 * * Individualized vs conven-onal COS in high responders Excessive response >20 oocytes retrieved; Mild/severe OHSS reported; Leão RBF, Nakano FY, Esteves SC. Fer5l Steril 2013; 100 (Suppl.): S16 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 17 2015 ANDROFERT *
- 18. Poor responders ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 18 2015 ANDROFERT • Main goal: pa-ent-‐centeredness • Clinical quality indicators: – Compliance (drop-‐out rate) – Pa-ent burden (cancela-on rate) • Protocol of choice*: Antagonist (flexible; cetrorelix) recFSH + recLH (follitropin alfa + lutropin alfa 2:1 ra=o: 300 IU recFSH + 150 IU recLH); start D1 s=mula=on *Androfert, Brazil
- 19. Pregnancy rates increased by 30% in poor responders treated with rLH+rFSH Lehert et al Reprod Biol Endocrinol 2014, 12:17 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 19 2015 ANDROFERT
- 20. Lehert et al 2012 Increase of ≈1 oocyte per 1,000 UI in poor responders treated with rLH +rFSH Lehert et al Reprod Biol Endocrinol 2014, 12:17 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 20 2015 ANDROFERT
- 21. Individualized vs. Conven-onal COS in Expected Poor Responders (N=118) 72.0 3.5 45.0 20.0 46.6 4.8 23.3 26.8 0 20 40 60 80 Observed Poor Response (%) Oocytes retrieved (N) Cancella=on (%) Pregnancy/cycle (%) cCOS (Long GnRHa + 300-‐450 IU recFSH alone) iCOS (GnRH antagonist + rFSH (225-‐300 IU) +rLH (75-‐150 IU)) Expected poor response: AMH<0.82 ng/dL; Observed poor response <5 oocytes retrieved; Leão RBF, Nakano FY, Esteves SC. Fer5l Steril 2013; 100 (Suppl.): S16 *p<0.05 * * * ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 21 2015 ANDROFERT
- 22. Normal responders ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 22 2015 ANDROFERT • Main goal: effec-veness • Clinical quality indicators: number oocytes • Protocol of choice*: <35yr: Antagonist + recFSH cetrorelix (flexible); 187.5-‐262.5 IU/d follitropin alfa pen injector >35yr: Antagonist + recFSH/recLH cetrorelix (flexible); follitropin alfa + lutropin alfa 2:1 ra=o; 225-‐300 IU/d; from s=mula=on D1 *Androfert, Brazil
- 23. Nega-ve predictor Posi-ve predictor van Loendersloot et al. Hum Reprod Update 2010; 16: 577–589 Female Age (OR=0.95; CI: 0.94-‐0.96) Number of oocytes retrieved (OR=1.04; CI: 1.02-‐1.07) Level 1a Predictors of pregnancy in IVF 14 studies >30,000 pa=ents ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 23 2015 ANDROFERT
- 24. What is the optimum number of retrieved oocytes to increase pregnancy rates ? a. 4 to 8 b. 9-12 c. 13-17 d. The higher the better
- 25. 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 20 25 30 35 40 Livebirthrate(%) Oocyte number Observed live birth rate Predicted live birth rate Sunkara et al. Hum Reprod 2011 450,135 IVF cycles Best chance of live birth is associated with ~15 oocytes number of oocytes that best optimized LBR was 15 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 25 2015 ANDROFERT
- 26. ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 26 2015 ANDROFERT ...irrespec-ve of age group
- 27. Do you take into account the severity of male factor infertility when planning COS? a. Yes b. No c. Never though about it
- 28. 41.4 47 43.3 20 100 64 61 34.2 Sperm retrieval (%) 2PN Fertilization (%) Top Quality Embryos (%) Live Birth (%) Non-obstructive (N=365) Obstructive (N=146) P<0.01 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 28 2015 ANDROFERT
- 29. 3,412 cycles Oocyte number and LBR at Androfert (ICSI cycles involving severe male factor) ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 29 2015 ANDROFERT 0% 10% 20% 30% 40% 50% 60% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 20 25 Number of oocytes Clinical pregnancy Live birth
- 30. Each addi-onal warming cycle increases the chance of achieving a live birth 40.4% 48.0% ET #3 (FET) 49 ET #2 (FET) 239 ET #1 (fresh) 822 50.5% +18.8% +25.0% Female Age ≤38 332/822 63/239 17/49 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 30 2015 ANDROFERT
- 31. Oocyte yield by gonadotropin ↑ 1.5 oocytes (GnRH antagonist cycles) Devroey et al., 2012 ↑ 3.1 oocytes (GnRH antagonist) Bosch et al., 2008 ↑ 1.8 oocytes (GnRH agonist cycles) MERIT Study, 2006 ↑ 2.8 oocytes (GnRH agonist cycles) Hompes et al., 2008 ↑ 2.1 oocytes (16 RCT; different protocols) Lehert et al., 2010 Higher with rec-‐FSH vs. hMG, HP-‐hMG, and uFSH ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 31 2015 ANDROFERT
- 32. LH supplementa-on improves clinical pregnancy in women >35 yr Hill et al. Fer5l Steril 2012 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 32 2015 ANDROFERT
- 33. LH ac-vity by rec-‐LH vs hMG Adapted from: Leao & Esteves. Clinics 2014; 69(4): 279–293. Product LH ac-vity (IU/vial) LH content* Purity hMG 75 hCG ~5% HP-‐hMG 75 hCG ~70% Lutroprin alfa (rec-‐hLH) 75 LH >99% 2:1 Follitropin alfa + Lutroprin alfa (rec-‐hFSH + rec-‐hLH) 75 LH >99% *hCG concentrated or added during purifica-on process (8IU hCG ~ 75IU LH) ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 33 2015 ANDROFERT
- 34. LH and hCG elicit different gene expression LH hCG LHR and FSHR expression (Trafficking of re=noic acid : RXRB, TTR, ALDH8A1) Meiosis and follicular matura-on (TRA : RXRB, TTR, ALDH8A1; IL11; AKT3) Follicular development (IL11; AKT3) Cellular growth (RXRB, TTR, ALDH8A1; IL11;AKT3) Ovarian stereodogenesis (TRA : RXRB, TTR, ALDH8A1) Embryo development & survival (AKT3) Aromatase inhibi-on (PPARS) Apoptosis enhancement (DNAsi) LH hCG Grondal ML et al. FerCl Steril 2009; Menon KM et al. Biol Reprod 2004; Ruvolo et al. Fer=l Steril 2007 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 34 2015 ANDROFERT
- 35. COS with LH ac-vity delivered by rec-‐ LH vs hMG in IVF Authors, yr. Design N Main findings Buhler & Fisher, 2011 Matched case-‐ control 4719 Higher CPR in fixed 2:1 rec-‐ FSH + rec-‐LH (31%) vs hMG (26%) and vs combo (rec-‐FSH + hMG, 25%); p=0.02 Fábregues et al, 2013 Cross-‐over study 66 Higher N oocytes in fixed 2:1 rec-‐FSH + rec-‐LH (9.8) vs HP-‐ hMG (7.3); p<0.01. Higher N frozen embryos in recLH Dahan et al, 2014 Observa=onal 201 Higher N oocytes in rec-‐LH (12) vs hMG (10); p=0.008. Higher CPR rec-‐LH (36% vs 20%; p=0.02) ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 35 2015 ANDROFERT
- 36. Individualizing trigger and LPS ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 36 2015 ANDROFERT High responders Normal responders Low responders Safety Pa-ent-‐ centeredness Effec-veness
- 37. 14h 14h 20h 48h 0 20 h Natural LH surge hCG Adapted from Chan et al. Hum Reprod. 2003;18:2294-‐7 Day 6 hCG and GnRHa elicit final follicular matura-on as surrogates for the mid-‐cycle LH surge GnRHa 36-48 h ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 37 2015 ANDROFERT Day 8
- 38. GnRH-‐agonist vs hCG trigger Fresh autologous cycles Moderate/ severe OHSS OR 0.10 0.01-‐0.82 Live birth OR 0.44 0.29-‐0.68 Youssef et al. Cochrane Database Syst Rev. 2011 High responders Fresh ET Freeze all GnRH-‐a trigger One size trigger does not fit all ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 38 2015 ANDROFERT
- 39. Freeze-‐all embryo policy: is it for all? • Non-‐inferior in effec-veness in high-‐ quality vitrifica-on programs, but… • Safety – Increase ART unit workload – Perinatal outcome • Higher rate of large for gesta-onal age (Wennerholm HR 2013) • Pa-ent-‐centeredness – Psychological & cost burden ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 39 2015 ANDROFERT
- 40. Modified LPS for fresh ET in GnRH-‐a trigger No. follicles day OPU 1,500 IU hCG at OPU & 1,000 OPU+5 & standard LPS ≤ 14 1,500 IU hCG at OPU + standard LPS 15-‐25 1,000 IU hCG at OPU + standard LPS or Freeze all 26-‐30 Freeze all >30 Humaidan et al. Hum Reprod. 2013;28(9):2511-‐21 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 40 2015 ANDROFERT 14h 14h 20h 48h 0 20 h 4h GnRHa Natural LH surge Luteal phase defect
- 41. Individualizing trigger ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 41 2015 ANDROFERT Normal & poor responders rec-‐hCG u-‐hCG hCG trigger
- 42. RCT N Effect Oocytes retrieved 9 1409 MD: -‐0.04 95% CI: -‐0.69 to 0.61 Live birth 6 1,019 OR: 1.04 95% CI: 0.79 to 1.37 Miscarriage 7 1,106 OR: 0.69 95% CI: 0.41 to 1.18 Severe OHSS 3 549 OR: 1.49 95% CI: 0.54 to 4.1 Youssef et al. Cochrane Database Syst Rev. 2011; 13(4):CD003719 Databases searched up to January 2010 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 42 2015 ANDROFERT
- 43. Farrag et al. JARG 2008; 25:461-6 8.4 7.3 7.1 4.7 0 2 4 6 8 10 No. Retrieved oocytes No. MII with mature cytoplasm rec-hCG (250 mcg; n=42) u-hCG (10,000 IU; n=47) *p<0.01 * ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 43 2015 ANDROFERT
- 44. Effec-veness RCT comparing trigger with rec-‐hCG (250 mcg) vs u-‐hCG (10,000 IU) on delivery rates in eSET antagonist cycles 26.7% 44.1% Delivery rate (%) u-hCG rec-hCG N=119 aged<32 OR: 2.16 (95% CI: 1.01-‐4.67; p=0.04) Papanikolaou EG et al. Fer5l Steril 2010; 94:2902-‐4 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 44 2015 ANDROFERT
- 45. RCT N Odds-‐ra-o Local site reac-ons* rec-‐hCG vs. u-‐hCG 3 374 0.39 95% CI: 0.25 to 0.61 Driscoll et al. 2000: 27% vs 42% ERHCG group 2000: 23% vs 45% Abdelmassih et al. 2005: 23% vs 45% Youssef et al. Cochrane Database Syst Rev. 2011; 13(4):CD003719 * Pain and/or inflammation ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 45 2015 ANDROFERT
- 46. hCG preferences in treatment-‐ experienced pa-ents at Androfert Total (n=76) 60% 29% 3% 8% prefer new pen prefer pre-filled syringe prefer lyophilized powder to reconstitute Not matter ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 46 2015 ANDROFERT
- 47. Individualizing LPS ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 47 2015 ANDROFERT Normal & poor responders Fresh ET FET
- 48. In FET cycles, all of the current methods of endometrial prepara-on appear to be equally effec-ve in terms of ongoing pregnancy rate* • Meta-‐analysis of 20 compara=ve studies • ~13,000 cycles • Natural and ar=ficial cycles with and w/o GnRH agonist • Safety & pa-ent-‐centeredness not addressed Groenewoud ER et al. Hum Reprod Update. 2013;19:458-‐70 *in eumenorrhoic pa-ents ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 48 2015 ANDROFERT
- 49. Luteal phase abnormal in s-mulated cycles • Corpus luteum func-on dependent on pulsa-le LH release from pituitary • Supraphysiologic steroid levels (by mul-follicular development) inhibits LH secre-on • Low LH levels causes luteolysis, implanta-on failure and shortened luteal phase Jones 1996; Albano et al 1998; Beckers et al 2000; Tavaniotou et al Hum Reprod 2000; Fauser & Devroey 2003; Trinchard-Lugan et al 2002; Sherbahn 2013 ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 49 2015 ANDROFERT
- 50. LPS mandatory in s-mulated cycles • hCG vs. Placebo or No treatment: Higher ongoing PR (OR=1.75; 95% CI: 1.09-2.81) • Progesterone vs. Placebo or No treatment: Higher clinical PR (OR=1.83; 95% CI: 1.29-2.61) Higher ongoing PR (OR=1.87; 95% CI: 1.19-2.94) Higher live birth rates (OR=2.95; 95% CI: 1.02-8.56) Level 1a ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 50 2015 ANDROFERT
- 51. Gelbaya et al Fertil Steril. 2008; Kolibianakis et al Hum Reprod. 2008; Jee et al Fertil Steril. 2010; van der Linden et al Cochrane Database 2011 High-‐quality evidence on LPS in s-mulated cycles ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 51 2015 ANDROFERT
- 52. P routes & types Evidence Effect Conclusion Vaginal as effective as IM/oral 13 RCT; 2 MA; >2,000 cycles Similar CPR, LBR & miscarriage True Vaginal safer and more patient- friendly than IM/oral 3 RCT; 1 MA; >2,000 cycles Lower side effects; Increased patient satisfaction True Among vaginal P, patients prefer gel 7 RCT; 1 MA; >2,400 cycles Easier to use; better adherence; lower discharge True Schoolcraft et al 2000; Yanushpolsky et al-2008; Zarutskie & Phillips 2009; Polyzos et al 2010; van der Linden et al Cochrane 2011 High-‐quality evidence on LPS in s-mulated cycles ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 52 2015 ANDROFERT
- 53. Principles and Prac-ces of Individualized ART at Androfert ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 53 2015 ANDROFERT High responders Normal responders Low responders Clinical features + AMH Antagonist protocol; tailored COS rec-‐FSH (112.5-‐150 IU) + tailored trigger (GnRHa or rec-‐hCG); tailored LPS (modified LPS or vaginal P gel OPU) Antagonist protocol; tailored COS w/rec-‐ FSH (<35yr) or rec-‐FSH+rec-‐LH 2:1 ra-o (>35 yr); rec-‐hCG trigger; LPS vaginal P gel Antagonist protocol; recFSH + recLH 2:1 ra-o + rec-‐hCG trigger; LPS vaginal P gel
- 54. Principles and Prac-ces of Individualiza-on in ART Conclusions • Individualiza-on is a quality concept • Safety, effec-veness and pa-ent-‐centeredness are important principles in a quality-‐based individualized infer-lity care • Novel biomarkers combined with new devices & drug regimens can be used to deliver a high quality evidence-‐based individualized ART ANDROLOGY AND HUMAN REPRODUCTION CLINIC - REFERRAL CENTER FOR MALE REPRODUCTION S ESTEVES, 54 2015 ANDROFERT
- 55. Thank you اشكر Obrigado This presenta-on is available at hwp://www.slideshare.net/ sandroesteves