02.11.2014

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Fertility in midlife women

Tevfik Yoldemir MD, BBA, MSc

Associate Professor

Marmara University, School of Medicine

Department of Obstetrics and Gynecology

Division of Reproductive Medicine

Istanbul, Turkey

tevfik@yoldemir.com

Follicle depletion

doi:10.1016/j.ijgo.2011.11.002

Ovarian response predictors

Am J Obstet Gynecol 2008;199:202.e1-202.e8.

Treatment alternatives

http://dx.doi.org/10.1016/j.fertnstert.2012.11.051

02.11.2014

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Poor ovarian response

Two out of three of the following criteria were essential

in order to classify a patient as poor ovarian

responder:

(i) advanced maternal age (≥40 years) or any other risk

factor for poor ovarian response;

(ii) a poor ovarian response (≤3 oocytes with a

conventional stimulation protocol); or

(iii) an abnormal ovarian reserve test (AFC<7 follicles or

AMH<1.1 ng/ml).

Hum Reprod 2011;26:1616–1624.

Prediction of POR

RBMOnline - Vol 17. No 4. 2008 508-514

doi:10.1016/j.fertnstert.2007.12.077 doi:10.1016/j.fertnstert.2007.12.077

doi:10.1016/j.fertnstert.2007.12.077

POR- stop vs non-stop long GnRHa

doi:10.1016/j.fertnstert.2007.12.077

02.11.2014

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POR- GnRH anta vs GnRH agon

doi:10.1016/j.fertnstert.2007.12.077

GnRH anta vs GnRH agonist

http://dx.doi.org/10.1016/j.fertnstert.2013.08.024

Luteal phase Anta vs Microdose flare

doi:10.1016/j.fertnstert.2008.04.024

Luteal phase Anta vs Microdose flare

doi:10.1016/j.fertnstert.2011.01.134

Androgen suppl

doi:10.1016/j.fertnstert.2011.04.083

POR – GH addition

doi:10.1016/j.fertnstert.2007.12.077

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Case 1

• 40 year-old woman

• Nulliparous

• Newly married ( 4 months)

• Cycle length longer than it is used to be

• FSH 14 IU/L

• She is worried about her chances for conception.

• How would you counsel her?

Low responder –before / after ART

doi:10.1016/j.fertnstert.2012.02.012

Low responder

doi:10.1016/j.fertnstert.2012.02.012 doi:10.1016/j.fertnstert.2011.06.072

Case 2

• 39 year-old woman

• Single

• Previous history of LS left endometrioma excision

• AMH 0.8 ng/ml

• Curious about her fertility potential.

• What would you advise her ?

doi:10.1016/j.fertnstert.2011.07.1102

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Predicting POR

doi:10.1016/j.fertnstert.2011.07.1102

AMH

Prediction for POR

doi:10.1016/j.fertnstert.2008.10.042

Women with extremely low (0.4 ng/ml) anti-

Mullerian hormone (AMH) concentrations

doi:10.1016/j.rbmo.2013.09.017

Women with extremely low (0.4 ng/ml) anti-

Mullerian hormone (AMH) concentrations

doi:10.1016/j.rbmo.2013.09.017

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Case 3

• 38 year-old woman

• Nulliparous

• Inhibin B = 50 pg/ml, AFC = 5

• Trying to get pregnant for the last 9 months

• She asks for treatment options?

doi:10.1016/j.fertnstert.2011.07.1102

Inhibin B / D5 Inhibin B

Prediction for POR

doi:10.1016/j.fertnstert.2010.03.009 doi:10.1016/j.fertnstert.2011.07.1102

Basal Inhibin B

Stimulated Inhibin B

Predicting POR

doi:10.1016/j.fertnstert.2011.07.1102

Case 4

• 40 year-old woman

• Had a pelvic scan and was told that her

ovaries “looked lazy”

• She is willing to find out her chances of

conception.

• Which other information would be relevant?

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AFC / AMH- prediction of POR

doi:10.1016/j.fertnstert.2008.10.042

AFC – ovarian response

doi:10.1016/j.fertnstert.2010.03.023

AFC – ovarian response

doi:10.1016/j.fertnstert.2010.03.023

AFC – Implantation R, Pregnancy R

doi:10.1016/j.fertnstert.2010.03.023

AFC

http://dx.doi.org/10.1016/j.fertnstert.2012.05.042

AFC vs AMH

doi:10.1016/j.fertnstert.2007.12.013

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Am J Obstet Gynecol 2008;199:202.e1-202.e8.Am J Obstet Gynecol 2008;199:202.e1-202.e8.

< 4 oocytes retrieved ≥15 oocytes retrieved

Advanced

age fertility

RBMOnline - Vol 19. No 4. 2009 599–603

IVF results >40 yrs (Ng 2007)

Case 5

• 34 year-old woman

• Has started COH for ART; only 3 follicles

developed.

• She wants to know what will happen next?

IUI vs IVF

http://dx.doi.org/10.1016/j.fertnstert.2013.02.049

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IUI vs IVF

http://dx.doi.org/10.1016/j.fertnstert.2013.02.049

IUI vs retrieval

doi:10.1016/j.fertnstert.2009.03.059

Ongoing PR

doi:10.1016/j.fertnstert.2012.03.014

High-responder Normo-responder Poor responderPOR Natural IVF cycles

doi:10.1016/j.fertnstert.2008.07.1765

Conclusions

• Better tailored COH protocols

• Time-lapse markers for better embryo

selection

• Tests (ERA) for the optimization of

endometrial receptivity

• Oocyte / ovarian tissue cryopreservation

http://dx.doi.org/10.1016/j.mam.2013.06.001

Improve ovarian response

http://dx.doi.org/10.1016/j.fertnstert.2012.10.011

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Time-lapse markers used for

clinical outcome predictions

http://dx.doi.org/10.1016/j.fertnstert.2013.01.143

Endometrial receptivity

http://dx.doi.org/10.1016/j.fertnstert.2012.12.005

Thank you for your attention

tevfik@yoldemir.com