Insight’16 – International Conference on Infertility & Endoscopy Coimbatore, INDIA – October 2 - 2016

1. www.androfert.com.br!
Sandro ESTEVES!
Medical and Scientific Director!
ANDROFERT - Andrology & Human Reproduction Clinic!
Campinas, Brazil!
Maximizing Outcomes in
ART by Individualization
Insight’16 – International Conference on Infertility & Endoscopy!
Coimbatore, INDIA – October 2 - 2016!

2. 1. Individualized COS
2. Reproductive Andrology
3. New paper-free IVF lab
4. Quality Management System (ISO 9001)
Esteves, 2 !
Strategic-focused Areas of Androfert

3. Technical
aspects
to
deliver
the
best
possible
outcome
(e.g.
pregnancy,
live
birth,
cumula9ve
LBR)
Complica9ons
(OHSS),
adverse
effects,
risks
(pa9ent
&
offspring),
errors/
mistakes
Safety
Patient-
centeredness
Effectiveness
Individualized management reflecting
quality dimensions
Respect
for
the
pa9ent’s
values
and
expressed
needs,
informa9on
and
educa9on,
access
to
care,
physical
comfort,
coordina9on
of
care,
emo9onal
support
Dancet
et
al.
Hum
Reprod
2011;
Mainz
Int
J
Qual
Health
Care
2013
Esteves,
3

4. 22 studies !
21,453 patients!
8 countries!
Poor quality of services provided and lack of
patient-centered care ~60% treatment discontinuation

5. • Fear
and
nega9ve
treatment
aStudes
• Sperm
retrieval
and
sperm
quality
• Communica9on
issues
with
partner
Verberg et al. Why do couples drop-out from IVF treatment: A prospective cohort study.
Hum Reprod 2008;23:2050-5
Hazard
Ra9o
4.80
(95%
CI:
1.63-­‐14.13)
Male infertility a risk factor for IVF dropout

6. Conventional semen
analysis
Conventional
surgeries
Sperm Function Testing
Microsurgery
Genetic diagnosis
YCMD
molecular
diagnosis
Empirical treatments
2. Reproductive Andrology
Empowering clinical decisions & treatment efficiency

7. 3.
“New’
IVF
Lab
–
Clean
room
Technology
Air
filtra9on
system
combining
par9cle
+
VOC
(carbon
+
potassium
permanganate)
filtra9on
ISO
5
Cleanroom
IVF
lab
+
Chemical
filtra9on

8. Esteves, 8 !

9. 0
100
before
a*er
%
TQE
0
50
before
a*er
%
miscarriage
0
50
before
a*er
%
LBR
2.3
3.2
Average
No.
Top
Quality
Embryos
ET
Conven9onal
lab
Cleanroom
lab
P=0.01
N=2315

10. 3. The new IVF laboratory
Paper-free
´ Error reduction
´ alert the user of inconsistencies
´ Information legible
´ Data search and reports
´ Track and analyze trends
´ QC/QA/QM activities
´ Improve clinic - patient communication
´ Improve confidentiality
´ Access to information from any device

11. 2016

12. Checklists
Esteves, 12 !

13. Case
study
Esteves, 13 !

14. 3. The new IVF laboratory
Clinical Information Systems

15. ISO
9001
cer9fied
since
2010
Bri8sh
Standards
Ins8tu8on
(BSI)
Esteves, 15 !
4. Quality Management System
Expresses
the
organiza9onal
structure,
policies,
procedures,
processes
and
resources
used
to
implement
quality
ac9ons

16. • Mission
• Quality
policies,
objec9ves
&
indicators
• Document
control
system
• Reviews,
audi9ng,
reten9on
• How
to
register
and
control
non-­‐conformi9es,
correc9ve
&
preven9ve
ac9ons
• Audi9ng
system
• Improvement
system
SOPs
• Laboratories
descrip9on
• Personnel,
job
descrip9ons,
responsibili9es
• Training
program
• Safety
instruc9ons
• General
rules
Technical
manual
Clinical
and
laboratory
SOP
manual
Quality
manual
4. Quality Management System

17. New stratification based
on “prognosis”
1. iCOS: paradigm change
Esteves,
17
Categories:
i. High
ii. Normal
iii. Low

18. 1. iCOS: Tools X Prognostic factors
•
Age
• Biomarkers
(AMH;
AFC)
• Farmacogenomics
• FORT
Number
of
Oocytes
Aneuploidy
Rates
IVF
Lab
Severe
Male
Factor
• Non-­‐obstruc9ve
azoospemia
• Sperm
DNA
fragmenta9on
• TQM
• Blastocyst
culture
• Time-­‐lapse
• Vitrifica9on
• PGD/PGS
Esteves,
18

19. 1. iCOS: Tools X Prognostic factors
• Biomarkers
(AMH;
AFC)
• Farmacogenomics
• FORT
Number
of
Oocytes
Aneuploidy
Rates
IVF
Lab
Severe
Male
Factor
Esteves,
19

20. Esteves,
20
Strong association between number of
oocytes and cumulative LBR (fresh+frozen)

21. La
Marca
and
Sunkara,
Hum
Reprod
Update
2014
Expectednumberof
oocytesXovarian
biomarkers
Esteves,
21

22. Esteves, 22 !

23. b. Hypo-responders
Ovaries less sensitive to stimulation
AMH & AFC not predictive
D1
D7
D12
Esteves,
23
Low follicle output rate (FORT*)
*Follicular
Output
Rate

24. • ~10%
pa9ents
with
normal
biomarkers
require
total
gonadotropin
dosage
>2500
IU
FSH
and
more
prolonged
s9mula9on
to
achieve
adequate
follicular
development
• Ovarian
response
subop9mal
(4-­‐9
oocytes)
• Genomic
profile
(polymorphisms)
b. Hypo-responders
Esteves,
24
Alviggi,
Humaidan
et
al
RBE
2013;
Alviggi,
Confor8
&
Esteves,
Springer
2016

25. Farmacogenomics
Hypo-­‐sensi9vity
to
gonadotropin
s9mula9on
related
to
presence
of
polymorphisms:
• LH
(v-­‐beta
LH)
• FSH
receptor
(variant
Ser/680)
Alviggi,
Humaidan
et
al
RBE
2013;
Alviggi,
Confor8
&
Esteves,
Springer
2016
Esteves,
25

26. Broer et al. Fertil Steril 2009 ; Broer et al. Hum Reprod Update, 17:46; 2011
Esteves, 26 !

27. 1. iCOS: Tools X Prognostic factors
•
Age
Number
of
Oocytes
Aneuploidy
Rates
IVF
Lab
Severe
Male
Factor
Esteves,
27

28. Aneuploidy rates X Age
70%
60%
50%
30%
15%
Esteves,
28

29. c. Age
Swiss
Registry
2015
(>100,000
cycles)
Esteves,
29

30. 1. iCOS: Tools X Prognostic factors
Number
of
Oocytes
Aneuploidy
Rates
IVF
Lab
Severe
Male
Factor
• Non-­‐obstruc9ve
azoospemia
• Sperm
DNA
fragmenta9on
Esteves,
30

31. Esteves,
31
d. Impact of severe male factor infertility

32. N=3,412 cycles; 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 oocytes retrieved
LBR as a function of number retrieved oocytes
in severe male factor infertility
Esteves, 32 !

33. Esteves,
33
26%
42%
IVF ICSI
Pregnancy rates cycles
with elevated SDF
Robinson et al. Hum Reprod 2012 !
Meta-analysis 16 studies;
2.969 couples:
Risk of miscarriage increased
IVF/ICSI cycles with high SDF
RR = 2.16
95% CI: 1.54-3.03; p<0.00001
Bungum et al. Hum Reprod 2007 !
Sperm DNA fragmentation

34. 147
Infer9le
men
with
oligozoospermia
(5-­‐15
M/mL)
and
persistent
high
SDF
(DFI>30%)
aoer
oral
an9oxidants
ICSI
with
ejaculated
sperm
(N=91)
ICSI
with
tes9cular
sperm
(N=81)
Fertil Steril 2015; 104(6):1398-405
Esteves, 34 !

35. Esteves, 35 ! Esteves et al. Fertil Steril 2015; 104(6):1398-405.!
SDF5-foldlowerin
testicularsperm

36. Esteves et al. Fertil Steril 2015; 104(6):1398-405.!
TESTI-ICSI option in cases of elevated SDF
Esteves, 36 !

37. 1. iCOS: Tools X Prognostic factors
Number
of
Oocytes
Aneuploidy
Rates
IVF
Lab
Severe
Male
Factor
• TQM
• Blastocyst
culture
• Time-­‐lapse
• Vitrifica9on
• PGD/PGS
Esteves,
37

38. 1. iCOS: Tools X Prognostic factors
•
Age
• Biomarkers
(AMH;
AFC)
• Farmacogenomics
• FORT
Number
of
Oocytes
Aneuploidy
Rates
IVF
Lab
Severe
Male
Factor
• Non-­‐obstruc9ve
azoospemia
• Sperm
DNA
fragmenta9on
• TQM
• Blastocyst
culture
• Time-­‐lapse
• Vitrifica9on
• PGD/PGS
Esteves,
38

39. Esteves,
39
POSEIDON concept: iCOS based on
prognostic categories and new marker
of successful treatment

40. 4 groups of low prognosisFour Groups of Patient with Lower Prognosis
GROUP 1
Young patients <35 years with adequate
ovarian reserve parameters (AFC≥5; AMH≥1.2
ng/ml) and with an unexpected poor or
suboptimal ovarian response.
Subgroup 1a: <4 oocytes*
Subgroup 1b: 4-9 oocytes retrieved*
*after standard ovarian stimulation
GROUP 2
Older patients ≥35 years with adequate
ovarian reserve parameters (AFC≥5; AMH≥1.2
ng/ml) and with an unexpected poor or
suboptimal ovarian response.
Subgroup 1a: <4 oocytes*
Subgroup 1b: 4-9 oocytes retrieved*
*after standard ovarian stimulation
GROUP 3
Young patients (<35 years) with poor ovarian
reserve pre-stimulation parameters (AFC<5;
AMH<1.2 ng/ml)
GROUP 4
Older patients (≥35 years) with poor ovarian
reserve pre-stimulation parameters (AFC<5;
AMH<1.2 ng/ml)
Alviggi et al. Fertil Steril in press
Poseidon
Group;
Alviggi
et
al.
Fer8l
Steril.
2016
Feb
24.
Four Groups of Patient with Lower Prognosis
GROUP 1
Young patients <35 years with adequate
ovarian reserve parameters (AFC≥5; AMH≥1.2
ng/ml) and with an unexpected poor or
suboptimal ovarian response.
Subgroup 1a: <4 oocytes*
Subgroup 1b: 4-9 oocytes retrieved*
*after standard ovarian stimulation
GROUP 2
Older patients ≥35 years with adequate
ovarian reserve parameters (AFC≥5; AMH≥1.2
ng/ml) and with an unexpected poor or
suboptimal ovarian response.
Subgroup 1a: <4 oocytes*
Subgroup 1b: 4-9 oocytes retrieved*
*after standard ovarian stimulation
GROUP 3
Young patients (<35 years) with poor ovarian
reserve pre-stimulation parameters (AFC<5;
AMH<1.2 ng/ml)
GROUP 4
Older patients (≥35 years) with poor ovarian
reserve pre-stimulation parameters (AFC<5;
AMH<1.2 ng/ml)
Alviggi et al. Fertil Steril in press
Esteves,
40

41. POSEIDON Working Group
New marker of successful outcome
Ability to retrieve the
number of oocytes necessary to
obtain at least one euploid embryo
for transfer in each patient
Esteves,
41
Poseidon
Group;
Alviggi
et
al.
Fer8l
Steril.
2016
Feb
24.

42. Esteves,
42
Transfer of euploid embryos eliminates
age-related decrease in implantation
Cortesia
de
F.
Ubaldi
&
L.
Rienzi
(GENERA;
Jan
2012-­‐Dez
2013)

43. N óvulos por
blastocisto
euploide
?!
?!
?!
N oocytes =! 1! / (% euploid embryos per age group)!
(%MII)x(%2PN)x(%Blastulation)!
How to estimate?
Esteves, 43 !
Age Aneuploidy
rate
<35 60!
35-39 50!
40-42 30!
N oocytes needed to
obtain 1 euploid
blastocyst
8.5!
10!
17!
N oocytes =! 1! / (% euploid embryos per age group)!
(0.75)x(0.65)x(0.40)!

44. u
rec-­‐LH
(75-­‐150
IU/d)
u
rec-­‐hFSH
u
GnRH
Antagonist
Esteves,
44
Four Groups of Patient with Lower Prognosis
GROUP 1
Young patients <35 years with adequate
ovarian reserve parameters (AFC≥5; AMH≥1.2
ng/ml) and with an unexpected poor or
suboptimal ovarian response.
Subgroup 1a: <4 oocytes*
Subgroup 1b: 4-9 oocytes retrieved*
*after standard ovarian stimulation
GROUP 2
Older patients ≥35 years with adequate
ovarian reserve parameters (AFC≥5; AMH≥1.2
ng/ml) and with an unexpected poor or
suboptimal ovarian response.
Subgroup 1a: <4 oocytes*
Subgroup 1b: 4-9 oocytes retrieved*
*after standard ovarian stimulation
GROUP 3
Young patients (<35 years) with poor ovarian
reserve pre-stimulation parameters (AFC<5;
AMH<1.2 ng/ml)
GROUP 4
Older patients (≥35 years) with poor ovarian
reserve pre-stimulation parameters (AFC<5;
AMH<1.2 ng/ml)
Alviggi et al. Fertil Steril in press
9
10-­‐17

45. Esteves,
45
rec$hLH(supplementa1on(
An1$apopto1c(
effect(on(
granulosa((
cells(
Up$regulate(
growth(factors(
Increase(FSH(
receptor(
responsiveness(
Act(
synergis1cally(
with(IGF$1(
Rimon E et al., 2004; Robinson RS et al., 2007;
Tilly JL et al., 1992; Peluso JJ et al., 2001, Ben-Ami I et al., 2009
LH supplementation

46. Role of LH in Hypo-responders
Esteves,
46
P<0.05

47.
↑
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
Oocyte yield by gonadotropin type

48. Recombinant FSH
• Selected for follicular phase
• Less sialic acid caps
• More basic
• Shorter half-life
• Higher biopotency
Urinary FSH
• Post-menopausal
• More sialic acid caps
• More acidic
• Longer half-life
• Lower biopotency
FSH isoforms
Esteves,
48

49. Mean
total
dose
(IU)
per
cycle
to
achieve
a
live
birth*
0
4,000
8,000
10,000
Rec-­‐FSH
HP-­‐hMG
6,324
7,739
hMG
9,690
*Mean
total
dose
per
cycle/Live
birth
rate
N=865; GnRHa down
regulation
Esteves SC et al. Reprod Biol Endocrinol 2009:7:111
52%
22%
Less rec-hFSH required per live birth
than hMG in ICSI cycles

50. Esteves,
50
GROUP 3
Young patients (<35 years) with poor ovarian
reserve pre-stimulation parameters (AFC<5;
AMH<1.2 ng/ml)
GROUP 4
Older patients (≥35 years) with poor ovarian
reserve pre-stimulation parameters (AFC<5;
AMH<1.2 ng/ml)
Alviggi et al. Fertil Steril in press

51. Esteves,
51
Ø Individualization: dosage, type, regimen
u GnRH
Antagonist
(trigger
with
hCG
or
GnRHa)
u Rec-­‐hFSH
(300
IU)
+
rec-­‐LH
supplementa9on
(150
IU/d)?
u Adjuvants:
GH;
DHEA,
testosterone
??
u Minimal
s9mula9on
(eg.
Poseidon
4)?
Ø AccuVit (oocytes/embryos): DUOSTIM; PGS
GROUP 3
Young patients (<35 years) with poor ovarian
reserve pre-stimulation parameters (AFC<5;
AMH<1.2 ng/ml)
GROUP 4
Older patients (≥35 years) with poor ovarian
reserve pre-stimulation parameters (AFC<5;
AMH<1.2 ng/ml)
Alviggi et al. Fertil Steril in press
Ø Egg donation

52. Esteves,
52
van
Disseldorp
et
al,
Hum
Reprod
2010
GnRH Antagonist Cycles
Allow evaluation of antral follicles pre-stimulation
Ø Decision of whether or
not start stimulation
Ø AFC variation low
ovarian reserve (-3; +7)
Ø Compatble with Duostim

53. Esteves,
53
rec$hLH(supplementa1on(
An1$apopto1c(
effect(on(
granulosa((
cells(
Up$regulate(
growth(factors(
Increase(FSH(
receptor(
responsiveness(
Act(
synergis1cally(
with(IGF$1(
Rimon E et al., 2004; Robinson RS et al., 2007;
Tilly JL et al., 1992; Peluso JJ et al., 2001, Ben-Ami I et al., 2009
LH supplementation

54. More
oocytes
and
less
cancela9on
with
rec-­‐hLH
supplementa9on
in
pa9ents
with
abnormal
markers
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)
Cancellation (%)
Pregnancy/cycle
(%)
rec-hFSH alone
r-hFSH+r-hLH 2:1 or 3:1 ratio
N=118; Expected poor response: AMH<0.82 ng/dL; Observed poor response <5 oocytes retrieved;
Leão RBF, Nakano FY, Esteves SC. Fertil Steril 2013; 100 (Suppl.): S16.
*p<0.05
*
*
*

55. First
world
conference
on
luteinizing
hormone
in
ART:
A
flight
of
discovery
27-­‐28
May,
2016
-­‐
Naples,
Italy
www.excemed.org

56. Purity
(LH
content)
FSH
activity
(IU/vial)
LH
activity
(IU/vial)
hCG
content
(IU/vial)
Specific
activity
(LH/mg
protein)
Lutropin alfa >99% 0 75¶
-- 9,000
Follitropin alfa
+ lutropin alfa
2:1 ratio
>99% 150 75 -- 9,000
HP-hMG Unknown* 75 75* ~8 --
¶1 µg of lutropin alfa = 22 IU
*derives primarily from the hCG component, which preferentially is concentrated during the purification process and sometimes
was added to achieve the desired amount of LH-like biological activity
Esteves & Alviggi. Principles and practices of COS in ART, Springer NY 2015
Gonadotropins with LH activity
Esteves,
56

57. No-­‐LH
37%
hMG
51%
rec-­‐LH
12%
REDLARA
No-­‐LH
42%
hMG
4%
rec-­‐LH
54%
ANDROFERT
How
ooen
ovarian
s9mula9on
protocols
with
exogenous
LH
are
used
in
our
clinical
prac9ce?
Years
2012-­‐2013;
Androfert
contributes
to
~1%
of
all
reported
cycles
to
REDLARA
63.1%
58.3%
The
Latam
Approach
SC
Esteves,
21

58. Esteves, 58 !
Abnormal ovarian
markers
(AFC, HAM)
1
Hypo-responders*
GnRH Antagonist
+ Age ≥ 35
Combination rec-hFSH (150-300 IU/d) + rec-hLH (75-150 IU/d);
ratio 2:1
Since stimulation day 1 (*D6-7 cycle rescue in hypo-responders)
Supplementation with LH - Androfert
3
2

59. Esteves, 59 !
Extracellular
fluid
Cytoplasm
Plasma
membrane
LH
hCG
LH/hCG
receptor
Beta unit
Carboxyl
terminal
Longer in
hCG
Higher
receptor
affinity
Present in hCG
but not in LH
Longer half-life
Leao & Esteves. Clinics 2014; 69(4): 279–293.

60. Esteves, 60 !
Choi & Smitz Mol Cell Endocrinol 2014; 383(1-2):203–13.
Differential cellular response post-receptor coupling

61. Esteves, 61 !
100 pM LH or hCG; n=4; Mean±SEM; *=significant vs unstimulated; t-test/two-
way analysis of variance; p<0.05. hGLC model
Casarini L et al. PLoS ONE 7(10): e46682, 2012.
ERK
1/2
AKT

62. Esteves, 62 !
Cellular Viability
Casarini et al., Mol & Cell Endo, 2016
Expression of pro-
apoptotic enzymes

64. Esteves, 64 !
Hypo-responders
2
Poseidon 1 (<35a) Poseidon 2 (≥35)
Pregnancy Rate
LH supplementation – Our experience

65. Esteves,
65
37%
22%
35-­‐39
≥40
LBR%
(ET
fresh)
Supplementação LH por faixa etária
2012-­‐2015;
N=1,229
cycles
with
complete
data
GnRH Antagonist
+ Age ≥ 35
3
Live birth
LH supplementation – Our experience

66. Esteves,
66
1
Poseidon 3
(<35a)
Poseidon 4
(≥35)
Duostim/Accuvit
Pregnancy Rate
LH supplementation – Our experience
Abnormal ovarian
markers
(AFC, HAM)

67. Esteves,
67
D1
D10
Poseidon; groups 3 and 4
Adapted
from
Ubaldi
et
al.
ASRM
2015
Duos8m

68. Esteves, 68 !
Poseidon
Group;
Alviggi
et
al.
FerTl
Steril.
2016
POSEIDON Concept
Stratification based on prognosis to guide individualized
management and new measure of successful treatment

69. Esteves, 69 !
1. Quality of infertility care should be measured not only by
effectiveness (cumulative live birth pregnancy) but also safety
and patient-centeredness
– Reducing dropout remains essential to enhance the beneficial
effect of treatment
2. Novel state-of-the art tools & devices helping to improve patient
adherence and clinical outcomes
– Fast-evolving iCOS, laboratory technology and online
connectedness will continue to redefine our practices
3. Quality Management Systems are customer-focused
– Implementation is a strategic decision that can provide competitive
business advantage
Key Messages

70. ANDROFERT - Campinas, Brazil!
Thank
you
धन्यवाद
Obrigado