Novel Biomarker Catalyst Lab In Vitro Fertilization - IVF sLHCGR - PowerPoint PPT Presentation

Novel Biomarker Catalyst Lab In Vitro Fertilization - IVF sLHCGR & LH-sLHCGR ELISA Distributed in the US by: www .E .EagleBio.c .com

In Vitro Fertilization  IVF is a treatment that is offered to couples with unexplained fertility, endometriosis or the female has blocked or an absence of fallopian tubes  All treatment centers use different drug protocols, the following example is a standard long cycle  IVF Stage 1 – Stop normal activity of ovaries  IVF Stage 2 – Stimulate ovaries / ovarian induction  IVF Stage 3 – Follicle count  IVF Stage 4 – Egg collection  IVF Stage 5 – Embryo transfer to the uterus *Medical condition in which cells from the lining of the uterus appear and flourish outside the uterine cavity ** Two tubes leading from the ovaries into the uterus

IVF Stage 1 - Stop normal activity ovary Diagnostics - Before starting the procedure  Determining factors for egg quality are  Day-3 FSH (Follicle Stimulating Hormone), high FSH (LH:FSH ratio) predicts  poor egg quality Ovarian reserve by AMH (Anti-Mullerian Hormone) and by antral follicular  count (AFC). Usually, low AMH means poor oocyte reserve & high AMH indicates polycystic ovary (risk of ovarian hyperstimulation) AMH is also useful for determining the correct dose of fertility drugs  Drugs  Nasal spray or subcutaneous injection of GnRH (Gonandotrophin releasing  Hormone) for approx. two weeks GnRH temporarily stops the normal activity of the ovary so that ovulation does  not occur when the ovaries are stimulated Diagnostics – After drugs  Ultra sound scan to ensure that the ovaries are inactive 

IVF Stage 2 – Stimulate ovaries / Ovarian induction Drugs  A second drug will be introduced, FSH (Follicle Stimulating Hormone) by  subcutaneous injection, on a daily basis FSH stimulates the ovaries to produce multiple follicles  Diagnostics  The progress will be assessed by ultra sound scans 3-4 times during this stage  E2 (Estradiol) and FSH are measured 3-4 times during this period  Direct correlation between the E2 value and the number of eggs/follicles  The physician uses the E2 and ultrasound result to determine if the treatment is  going well If a patient is hyper-stimulated and develops too many eggs, the cycle is usually  cancelled

IVF Stage 3 – Follicle Count The follicles will be counted and measured by echography. A size of  approx.18mm indicates mature egg may be present (not all follicles will contain eggs) Depending on the number and size of the follicles, egg collection will be  scheduled Drugs  If the ovaries have responded well,  injection with a third drug, hCG will be administered Approx. 36 hours prior to the  scheduled egg collection hCG helps to mature the eggs present  and release the eggs in the follicles for the egg collection Diagnostics  On the day of the hCG trigger, the  E2/follicle ratio should be approx. 100- 200 and the Progesterone level should be 0.8 ng/mL

IVF Stage 4 – Egg collection The egg collection (oocyte retrieval) performed  under general anesthetic or sedation Vaginal probe with a needle attached to it and  is passed through the vaginal wall into each ovary under ultra sound guidance The follicles are individually drained and  embryologist checks the follicular fluid for eggs. Once the eggs have been retrieved they will be  left to rest in an incubator Later that day they will then be mixed with a  high concentration of prepared sperm. They will then be checked the next day for fertilization The embryos are checked on day 2/3 of  development. If they are progressing as expected then it may be recommended to aim for a blastocyst transfer on day 5

IVF Stage 5 – Embryo replacement Discussion of the number and quality of embryos to be replaced will take place  A fine catheter containing the embryo/ embryos is passed through the cervix and  deposited in the uterus. This is performed under ultra sound guidance Drugs  Progesterone is administered to maintain the  thickness of the lining of the uterus to aid implantation Taken in the form of intra-muscular injection or  suppository prior to the day of the embryo transfer and continued until the pregnancy test Diagnostics  If successful, the hCG test will be positive on the  14th day after egg retrieval The hCG doubles every 48 hours and is  monitored throughout the pregnancy

Complications during IVF OHSS – Ovarian Hyper Stimulation  Complication from fertility medication, in particular hCG used as a trigger in  Stage 3 Presence of multiple luteinized cysts within the ovaries  Classification  Mild – Ovaries are enlarged (5-12 cm), accumulation of ascites, abdominal  pain, nausea and diarrhea Severe – Hemoconcentration, thrombosis and distention, oliguria, pleural  effusion and respiratory distress. Complications of OHSS  Ovarian torsion, ovarian rupture, thrombophlebitis and renal insufficiency  About 5% of the treated patients may encounter moderate to severe OHSS 

Causes of Infertility PCOS – Polycystic Ovarian Syndrome  Multiple cysts in the ovary. These “cysts” are actually immature follicles, not cysts  One of the most common female endocrine disorders and produces symptoms  in 5-10% of women of reproductive age (12-45 years) One of the leading causes of female infertility  Majority of patients with PCOS have insulin resistance and/or are obese  30% of PCOS women can not be diagnosed with ultrasound  Medical conditions such as diabetes and thyroid disorders 

Novel Biomarker LH-sLHCGR LH & hCG have the same receptor: LHCGR hCG hCG sLHCGR sLHCGR LH LH sLHCGR Two hormones One receptor

Potential sLHCGR/LH-LHCGR ELISA Women who produced < 7 oocytes or > 15 oocytes had low concentrations of  sLHCGR and a good IVF outcome (i.e. pregnancy) A high level of sLHCGR was indicative of a poor IVF outcome (i.e. not pregnant)  An intermediate number of oocytes (8-14) the levels of sLHCGR did not appear  to affect pregnancy LH-LHCGR is usually undetectable in women with recurrent miscarriage prior to  (pre-treatment) and following implantation Pre-treatment serum sLHCGR/LH-sLHCGR and LH levels could provide an indication  of functional LH levels that would allow the adjustment of hormone dose prior to ovarian induction (Stage 2) This could be an important step towards avoidance of OHSS, particularly for  patients whose AMH levels do not correlate with high oocyte yield and potential OHSS New tests could be useful in avoiding OHSS and may help circumvent a situation  where all embryos need to be frozen If used before uterine transfer of the embryo, these assays may also identify those  women who may benefit from short-term supplementation with hCG in order to firmly establish the pregnancy

Market IVF Europe leads the world in ART (Assisted Reproductive Technology), initiating approx.  71% of all reported ART cycles (not including Asia) In 2009 there were reported 537.000 treatment cycles from 33 European countries  and compares with 142.000 cycles from the US and 57.000 from Australia and New Zealand France - 75.000 cycles  Germany – 68.000 cycles  Spain – 54.000 cycles  UK – 54.000 cycles  Italy – 52.000 cycles  Sweden – 17.000 cycles  Denmark – 14.000 cycles  Most active countries in the world are the USA and Japan  Annual growth of 5-10% over the last few years in the developed countries  Worldwide approx. 1,5 million ART cycles each year. 500.000 of these ART cycles are  conventional IVF treatments Source: European Society of Human Reproduction and Embryology

AMH versus sLHCGR/LH-sLHCGR AMH sLHCGR/LH-sLHCGR Ovarian reserve assessment Ovarian reserve assessment AMH low or high -> reduced oocyte yields Not an indicator of ovarian reserve Responsiveness to IVF Responsiveness to IVF No correlation between AMH and the embryo Women who produced < 7 or > 15 oocytes had low implantation potential concentrations of sLHCGR and a good IVF outcome (i.e. pregnancy). Women with undetectable pre- treatment sLHCGR tend to miscarry. PCOS PCOS AMH 3x higher in case of PCOS LH-sLHCGR in combination with LH, FSH & AMH helps to identify patients with PCOS. AMH fails to predict PCOS in a significant number of women. In this group of patients with normal AMH, low-to-undetectable pre- treatment sLHCGR can identify women susceptible OHSS. OHSS OHSS High AMH -> Risk of OHSS; in only in about half of LH-sLHCGR in combination with LH/FSH ratio could be the cases useful in avoiding OHSS Hormone drug dose Hormone drug dose Women with very high pre-treatment AMH could Pre-treatment serum sLHCGR/LH-sLHCGR and LH levels be sensitive to hormonal stimulation would allow the adjustment of hormone dose prior to ovarian induction