1. EOFF 2012, Dubai – Nov 22
Improving Success by
Tailoring Ovarian
Stimulation
Sandro Esteves, M.D., Ph.D.
Director, ANDROFERT
Center for Male Reproduction & Infertility
Campinas, BRAZIL

2. What is in it for me?
Learn the primary factors affecting ovarian
response to stimulation and the importance
of knowing your patients’ profiles.
Learn the best OS strategies to minimize
complications in “high responders” while
maintaining sustainable pregnancy results.
Learn the best OS strategies to maximize
pregnancy outcomes in “poor responders”.
Esteves, 2

3. Improving Success by Tailoring
Ovarian Stimulation
Esteves, SC – EOFF 2012
Review this Lecture at:
http://www.androfert.com.br/review
Esteves, 3

4. Factors Determining Response
to Ovarian Stimulation
 Demographics and
anthropometrics (Age,
BMI, Race)
 Genetic profile
 Cause of Infertility
 Years of Infertility
 Health status
 Nutritional status
Esteves, 4

5. Long-
r-hFSH
r-hFSH acting
u-FSH HP FbM
+r-hLH r-hFSH;
Pituitary r-hFSH FbM
u-FSH
FSH
u-hMG
Puriity
Horse and
Safety, Quality,
PMSG Specific
Consistency and Patient
Activity
Convenience
1930s 1950 1980 1995 2003 2007 2010
Intramuscular administration sc Injector
pens
sc, subcutaneous; FbM, filled by Mass; HP, highly-purified
Adapted from Lunenfeld. Hum Reprod Update 2004;10:453–67
Esteves, 5

6. Urinary vs. Recombinant
The endless debate…
Meta-
analyses of Number Number
Statistical Clinical
rec-hFSH vs of RCTs of
significance significance
HMG/HP- included couples
HMG/uFSH
Coomarasamy 7 2,159 LBR (RR = 1.18, 95% CI: 4% difference in
et al, 2008 1.02 to 1.38, P<0.03) in LBR in favor of
favor of HMG HMG (CI: 1%-?)
Insufficient evidence
Al Inany et al,
6 2,371 of a difference in odds None
2009
of pregnancy or live birth
Van Wely et al, 28 7,339 Insufficient evidence None
2011 of a difference in odds
of live birth
Subgroup analysis of r- For a LBR of 25%,
hFSH vs HMG in favor of use of rFSH rather
HMG (OR 0.84, 95% CI than hMG would
0.72 TO 0.99; N=3,197) result in a LBR
19%-25%
Coomarasamy et al, Hum Reprod. 2008;23:310-5; Al Inany et al, Gynecol Endocrinol. 2009;
Esteves, 6
25:372-8; Van Wely et al. Cochrane Database Syst Rev. 2011; 2:CD005354

7. Define your patient population and your
results by “Data Mining” your own database.
What are the best strategies to individualize
COS for my patient population?
Search the literature for relevant studies
that match your patient profile.
Esteves, 7

8. Data Mining

9. Up to Prevalence of Infertile Patients
(WHO II) with PCO in Clinical
68% Practice1
40
35
 Cancellation Rate
30  < 4 oocytes
25
20
• Prevalence of Patients
15 with Poor Response to
10
5 Ovarian Stimulation2
0
< 30 30-35
years years
36-39
years
40-42 >42 Up to 45% Infertility
years years
Patients aged 35 or
above1
1Reproductive Hormones Report - GCC Countries (Feb 2011)
2Bologna criteria: Ferraretti et al. Hum Reprod 2011.
Esteves, 9

10. Reproductive Biology and Endocrinology 2009; 7:111.
Unselected group of 865 NG down-regulated women
Group A (hMG; N=299)
Group B (HP-hMG; N=330)
Group C (r-hFSH; N=236)
Day
Day 1 Day 6 of hCG
Cycle
day 21 Gonadotropin rFSH/hMG
Individualized dose
112.5-450 UI Vaginal
progesterone
Agonist (nasal spray): Nafarelin acetate (400 mcg/day; fixed)
menses
Esteves, 10 Day 2-5 of menses

11. Esteves et al. (observational study 2009)
Outcome Measure HMG HP-hMG r-hFSH P-
n=299 N=330 n=236 value
Total gonadotropin dose (IU) 2,685 2,903 2,268 <0.01
Retrieved oocytes (N) 10.9 10.7 10.8 NS
MII oocytes (N) 8.9 8.9 8.7 NS
2PN fertilization rate (%) 72 72 71 NS
Implantation rate (%) 24 27 23 NS
Live birth rate per cycle (%) 24.4 32.4 30.1 NS
Moderate/severe OHSS(%) 2.3 1.8 1.3 NS
Esteves et al, Reprod Biol Endocrinol. 2009; 7:111
Esteves, 11

12. Esteves et al. (observational study 2009)
Total Dose per Live Birth (IU)* To achieve a
live birth,
10,000
52.2% 9,690 21-52%
more HP-
7,000 21.6% 7,739
hMG and
6,324* hMG was
3,000
required
0
compared
r-hFSH HP-hMG hMG with r-hFSH
* Mean total dose per cycle/Live birth rate (≤35 years)
Esteves, 12

13. Esteves et al. (observational study 2009)
% Cycles with “Step-down”
during ovarian stimulation
53.4*
*P<0.01
18.7 20.3
HMG HP-HMG rec-hFSH (fbm)
Esteves, 13

14. Improving Success by Tailoring
Key Points Ovarian Stimulation
 Patient variability excludes the possibility of a
single approach to controlled ovarian
stimulation.
 Overall, recombinant and urinary
gonadotropins have similar clinical efficacy.
However, it is important to determine how a
given protocol works for you by defining your
patient population and data mining your
experience.
Esteves, 14

15. What are the best strategies to individualize
COS for my patient population?
 Search the literature for relevant studies
that match your patient profile.
Esteves, 15

16. Central
Paradigm
Maximize Minimize
beneficial effects complications
of treatment and risks
High-quality Cycle cancellation,
oocyte yield OHSS, multiple
pregnancy
Esteves, 16 Fauser et al., 2008

17. Level
1a
Female Age Negative
Duration of infertility Predictors
Basal FSH
Type of infertility All reflecting
Indication ovarian
reserve
Fertilization method
Number of oocytes retrieved Positive
Number of embryos transferred Predictor
Embryo quality
van Loendersloot et al.
Esteves, 17 Hum Reprod Update 2010; 16: 577–589.

18. Level Pregnancy by number of oocytes
1a Markers of retrieved after mild (♦ ) or conventional
( ) ovarian stimulation for IVF
Ovarian
Response ⑤
⑩
Age
Biomarkers
● Hormonal Biomarkers
FSH, Inhibin-B, AMH
● Functional Biomarkers
Antral Follicle Count (AFC)
● Genetic Biomarkers
Single Nucleotide Polymorphisms
for FSH-R/LH/LH-R/E2-R/AMH-R Verberg M et al. Hum. Reprod. Update
2009;15:5-12
Esteves, 18

19. Level
1a
AMH = AFC >Inhibin B >FSH >Age
Predictor
of Poor
Predictor of Excessive Response Response
● AFC studies
 AMH Studies
Predictor of
Pregnancy
In ART
● AFC studies
 AMH Studies
Broer et al. Hum Reprod Update 2011 Broer et al. Fertil Steril 2009
Esteves, 19

20. Level AMH and AFC to Determine
2a
Who is Who Prior to OS
Response to Anti- Antral False
Ovarian Mullerian Follicle Positive
Stimulation Hormone Count Rate
(ng/mL)
Risk of Excessive
Response (≥15 ≥ 3.5 > 15
oocytes or OHSS)
Risk of Poor ~15%
Response < 1.1 <5
(≤ 4 oocytes)*
pmol/L X1000/140
*Bologna criteria: Ferraretti et al. Hum Reprod 2011; Broer et al. Hum Reprod Update 2011;
Esteves, 20 Nelson et al. Hum Reprod. 2009; Broer et al. Fertil Steril. 2009; Hendricks et al. Fertil Steril 2007.

21. High Responders
Poor Responders
Esteves, 21

22. Level Low Starting Doses of
2a
r-hFSH for Ovarian Stimulation in
High Responders
Clinical pregnancy rates/cycle
started
Individualized
60%
dosing in
50%
increments of 37.5 50.0%
IU of folitropin alfa 40%
possible by FbM 30% 35.3%
31.3% 31.1%
technology
20%
20.0%
Age (28-32) 10%
Oocytes retrieved 0%
75 IU 112.5 IU 150 IU 187.5 IU 225 IU
(8-12)
Olivennes F, et al. The CONSORT study.
Esteves, 22 Reprod Biomed Online. 2009;18:95–204.

23. Level GnRH Antagonist Protocol in
1a
High Responders
9 RCT; 966 PCOS women Relative Risk
Duration of ovarian stimulation -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 20% vs 32%
Mild 1.23 (95% CI 0.67-2.26)
Moderate and Severe 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)
40% reduction in moderate/severe OHSS by
using antagonists rather than agonists
Esteves, 23 Pundir J et al. RBM Online 2012; 24: 6-22.

24. Level GnRH Agonist for LH
1a
Triggering in High Responders
 GnRH-a triggering (0.2-1.5 mg): antagonist protocol;
 Reduced if not eliminated risk for OHSS;
 Challenge is to rescue luteal phase:
Vitrification and FET (Garcia-Velasco, Fertil Steril, 2012)
Modified LP support (Humaidan et al., 2011)
11 RCT – 1,055 women (GnRH Agonist vs hCG triggering)
Moderate/
LBR OPR
severe OHSS
Fresh autologous OR 0.44 OR 0.45 OR 0.10,
cycles (8 RCT) (0.29 - 0.68) (0.31 - 0.65) (0.01 to 0.82)
Donor recipient OR 0.90 OR 0.91 OR 0.06
cycles (3 RCT) (0.57 - 1.42) (0.59 -1.40) (0.01 - 0.31)
Youssef et al. Cochrane Database Syst Rev. 2011
Esteves, 24

25. Improving Success by Tailoring
Key Points Ovarian Stimulation
Best Strategies to Maintain
Sustainable Pregnancy Results Evidence
and Minimize Complications in
“High” Responders
Low Starting Doses of r-hFSH, preferably 2a
filled by mass preparations
GnRH Antagonists 1a
GnRH Agonist for LH Triggering* 2b
*Lower PR in fresh transfers
Esteves, 25

26. Less Sensitive Ovaries On the other hand…
• 15-20% of NG women have less
sensitive ovaries Reduced oocyte quality
• Older patients (≥35 years)
• Poor responders Reduced Fertilization Rate
• Slow/Hypo-responders
Reduced Embryo Quality
• Deeply suppressed endogenous
LH (endometriosis) Increase Miscarriage Rates
Westergaard et al., 2000; Esposito et
al., 2001; Humaidan et al., 2002
Reduced Androgen Decreased Reduced
ovarian LH receptor LH
secretory numbers of
paracrine poly- bioactivity
capacity functional
activity morphisms while
reduced LH
receptors imnuno-
• Piltonen et al.,
reactivity
Hurwitz & Alviggi et al., unchanged
Santoro 2004 2006 2003
• Vihko et al. 1996
• Mitchell et al.
1995; Marama et
al 1984
Esteves, 26

27. Level GnRH Antagonists in Poor
1b Responders
14 RCT (1,127 patients)
Duration of Number Cycle Clinical
stimulation Oocytes cancellation Pregnancy
retrieved
-1.9 days -0.17 1.01 1.23
(-3.6; -0.12) (-0.69; 0.34) (0.71; 1.42) (0.92, 1.66)
 Limited Clinical Benefit
Shortcomings:
- Definition of poor responders
- Different gonadotropins regimens for OS
Esteves, 27 Pu D et al. Hum Reprod. 2011; 26: 2742.

28. Level
1a
Meta-analytic Effect on
Intervention Population
Studies Pregnancy
Kyrou et al,20091 Poor Higher LBR1,2,3
Growth
Hormone1
Kolibianakis et al, 20092 responders Higher PR2
Duffy et al, 20103 Higher CPR3
Transdermal Poor Higher LBR
Bosdou et al , 2012
Testosterone2 responders Higher CPR
GH: IGF-1 and 2; oocyte quality and response to OS
4-24 UI/day; SC; different protocols
Testosterone: increase in intra-ovarian androgens
~1mg/d nominal delivery rate; pre-OS (15-21d)
Kolibianakis et al, Hum Reprod Update 2009,15:613-22; Kyrou et al, Fertil Steril̀ 2009;91: 749–66; Duffy et al,
Cochrane Database Syst Rev 2010;1:CD000099; Mochtar MH et al. Cochrane Database Syst Rev.
Esteves, 28 2007,2:CD005070; Bosdou JK et al, Hum Reprod Update 2012;8:127-45

29. Level LH Supplementation in Poor
1a Responders…
Effect on
Regimen Outcome
Pregnancy
Mochtar et al, 2007
r-hFSH+rLH vs. OR 1.85
3 RCT (N=310) OPR
r-hFSH alone* (95% CI: 1.10; 3.11)
Poor responders
CPR RD: +6%,
Bosdou et al, 2012 r-hFSH+rLH vs. (95% CI: -0.3; +13.0)
7 RCT (N= 603) r-hFSH alone*
Poor responders LBR RD: +19%
(only 1 RCT) (95% CI: +1.0; +36.0%)
Hill et al, 2012
r-hFSH+rLH vs.
7 RCT (N=902) OR 1.37
r-hFSH alone CPR
Women advanced (95% CI: 1.03; 1.83)
age ≥35 yrs.
*long GnRH-a protocol; OR=odds-ratio; RD=risk difference
Mochtar MH et al. Cochrane Database Syst Rev. 2007;2:CD005070; Bosdou JK et al,
Esteves, 29 Hum Reprod Update 2012; 8(2):127-45. Hill MJ et al. Fertil Steril 2012; 97:1108-4.

30. Level
1b LH Supplementation in Slow
Responders…
RCT 260 pts; “Steady” response on D8 (E2
<180pg/mL; >6 follicles <10mm)
Mean No. oocytes retrieved IR (%) OPR (%)
40
32
22
18
14
10 9 11
6
FSH step-up (+150 UI) LH supplementation Normal Responders
(+150 UI)
Esteves, 30 De Placido et al. Hum Reprod. 2005; 20: 390-6.

31. What is the optimal LH
supplementation protocol?
 Existing studies give us some clues but the
optimal LH protocol has yet to be established
 How much LH should be used?
 Should the dose be fixed or flexible?
 At what stage of the cycle should LH be
administered?
FSH
LH
2:1? 1:1? Fixed? Mimic of
natural LH levels?
Esteves, 31

32. Level
2a r-hFSH + r-hLH (2:1 fixed ratio) vs.
urinary hCG-based LH
Matched case-control study;
N=4,719 pts.; long GnRH-a protocol
35
30 Duration of
P=0.02 31 Stimulation (days)
25
26 25 Mean No. oocytes
20 retrieved
15
IR (%)
10
5 CPR per transfer
(%)
0
2:1 r-hFSH+r- HMG rec-hFSH +
hLH HMG
Esteves, 32
Buhler KF, Fisher R. Gynecol Endocrinol 2011; 1-6.

33. LH activity derives from hCG in HMG; hCG is
concentrated or added during purification;
Lower gene expression (LH/hCG receptor, etc.)
in granulosa cells of pts. treated with HMG:
May reflect down-regulation of LH receptors by constant
ligand exposure during the follicular phase due to longer
half life and higher binding affinity of hCG to LHr.
Preparations used are important for granulosa cell function
and may influence the developmental competence of the
oocyte and the function of corpus luteum.
ASRM Practice Committee. Fertil Steril. 2008; 90:S13-20; Trinchard-Lugan I et al. Reprod
Biomed Online 2002; 4:106-115; Menon KM et al. Biol Reprod 2004; 70:861-866;
Esteves, 33 Grondal ML et al. Fertil Steril 2009; 91: 1820-1830.

34. Improving Success by Tailoring
Key Points Ovarian Stimulation
Best Strategies to Maximize
Pregnancy Results Evidence
and Minimize Complications in
“Poor” Responders
Adjuvant Therapy 1a
LH supplementation
Poor responders 1a
Advanced age (≥35) 1a
Slow/Hypo responders 1b
Esteves, 34

35. Level A Final Word on LH
1b Supplementation: OI/IUI
LH levels 1.2 UI/L (WHO group I)
Higher follicular development pts. receiving LH (67% vs 20%;
p=0.02): Shoham et al., 2008.
Similar follicular development HMG vs FSH+rLH; higher
cumulative PR after 3 cycles in FSH+LH (56% vs 23%; p=0.01):
Carone et al., 2012.
WHO group II
Clomiphene-resistant: fewer intermediate-sized follicles and OHSS in
LH-supl. vs FSH group; similar ovulation rate (Plateau, 2006);
Previous over-response: higher monofollicular development in LH group
(32% vs 13%; p=0.04): Hughes et al., 2005;
IUI: higher monofollicular development in LH group without
intermediate-size (42% vs 11%; p=0.03); lower cycle cancellation due
to risk OHSS (-7% difference): Segnella et al., 2011.
Esteves, 35

36. Thank you.