Dr RAMA RAJU Dealing with ART failure what

– Dr. RAMA RAJU Dealing with ART failure – what should be the stimulation we offer

LITERATURE REVIEW ART FAILURE STIMULATION ?

ART FAILURE : Question 1 WITH EMPTY FOLLICLES ?

Empty follicle syndrome Genuine EFS False EFS Incidence 0. 08% Poor responder excluded on , 4 follicle

Empty follicle

Diagnostic marker Hcg • 5 to 100 IU/L Gnrh progesterone 3. 5 ng/ml • lh >8 iu/l or 15 IU/l

Etiology genuine empty follicle syndrome Lhcgr p. N 400 Chromosome 2 inversion p 11 q 21

Hcg dose Gnrh dose Location of injection Cold chain 25 degree BMI Timing False empty follicle syndrome

Question • Art failure due to few oocytes ?

Poor responder Afc Low Amh Low Ovarian Volume low Shorter cycles

Poor responder short protocol Lh supplementation ? Rec FSH 300 Or Hmg 450

POOR RESPONDER OPTIONS ARE LIMITED HYPORSPONDER OPTIONS PRESENT

QUESTION 4 What is difference between HYPO vs POOR • How many oocytes did I anticipate? • HYPORESPONDER • POOR RESPONDER

QUESTION 4 • WHERE CAN I USE LH SUPPLEMENTATION?

HYPORESPONDER

with optimum dose • BMI • age • afc lower rate of follicle • • AFC good But not many coming up growth lower e 2 • day 6 • day 8 On going poor responder add lh

Lh supplementation hypo responder

• Did I get the optimal number ? Question • UNENDING DEBATE

Ovarian stimulation protocols for IVF: is more better than less? Download PDF Reproductive Bio. Medicine Online. Alper, Michael M. ; Fauser, Bart C. . Published April 1, 2017. Volume 34, Issue 4. Pages 345 -353. © 2017.

Fauser, B. C. , Nargund, G. , Andersen, A. N. , Norman, R. , Tarlatzis, B. , Boivin, J. , Ledger, W. , 2010. Mild ovarian stimulation for IVF: 10 years later. Hum. Reprod. 25, 2678– 2684. • Conventional ovarian stimulation protocols aim to maximize the number of oocytes collected to obtain more embryos, thus enabling the selection of the best quality embryos for transfer and the generation of surplus embryos that can be cryopreserved for use in additional, unstimulated cycles (Fauser et al. , 2010).

Current tools are too few E 2 Follicle size number

Isuog 2017 sep

Question • Is there a negative effect of high egg yields on embryo cryopreservation and embryo quality

Fatemi HM et al. , High ovarian response does not jeopardize ongoing pregnancy rates and increases cumulative pregnancy rates in a Gn. RHantagonist protocol, Human Reproduction 2013; 28(2):

Percentage of cycles with cryopreservation and increasing oocyte yield ( Baker et al. , 2015 ). Based on Society for Assisted Reproductive Technology (SART) data from 2004– 2010.

Question 6 • ART FAILURE DUE TO CANCELLED CYCLE DUE TO EXCESSIVE RESPONSE/COASTING ?

Prediction Prevention Planning • AMH • AFC • BMI • ANDROGENS • Ocp • Progesterone • ? metformin • selection of protocol

Hyper responder

EVOVLING PHARMACOGENOMICS DOSAGE NORMOGRAM, • LHCGR 312 AA • FSHR 29 GG • RS NO 4073366

Question 7 • I have a 40 years failed ivf ? • Any tools for improving quality of oocytes

1 ANEUPLOIDY 5 TH DECADE 2 MITOCHONDRIAL DYSFUNCTION 3 Central role of oxidized coenzyme Q 10 (Co. Q 10) as an electron and proton transporter; describes the sites of reactive oxygen species (ROS) production and the Q cycle

Role of Mitochondrial DNA : MUTATION Aging oocyte Co. Q 10 STATINS Alpha lioic acid How long and when ?

Question • What is duostim concept ? • Does it have a relevance in a failed ivf cycle

DOES DUOSTIM HASA REVELANCE ? When should I cosider Whats the evidnece

DOES DUOSTIM HASA REVELANCE ? 1 When should I consider? POOR OVARIAN RESERVE CANCER PATIENTS 2 What's the evidence ? VERY LIMITED

Question 9 • What is Lhcgr and fsh receptor polymorphism

LH polymorphism phamacogenomics. A few words

SMALLER DOSE

NO ROLE OF LH HIGH RESPONDER

LH NEED

LH polymorphism 1500 patients 2012 -2016 1 2 312 position 6 base pair insertion • wild • Heterozygous • homozygous • heterozygous • homozygous

LH polymorphism AND Lh supplemetation 312 position • wild • Heterozygous • homozygous Need LH supplementation • heterozygous • homozygous

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