The outcome of oocyte freezing as compared with embryo freezing

Filippo Maria Ubaldi

M.D. M.Sc.

CLINICA VALLE GIULIA, Rome

3° Congress of Society of Reproductive Medicine

Antalya 5-9 October 2011

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Oocyte cryopreservation

“Need” or “no need”?

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“No need”

Oocyte cryopreservation

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No need?

Medical reasonMalignant diseasesSurgical ovary removalPolycystic ovaryHyperstimulation syndromePremature menopause etc.

Oocyte cryopreservation

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No need?

Logistic reasonsSperm collection problem

Legal reasonsRestrictions in embryo cryopreservationFate of embryos of separated couples

Social reasonsWish to delay motherhood

Moral reasons

Oocyte cryopreservation

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No need?

Oocyte donationOocyte banks may result in

- widespread availability- shortened, eliminated waiting list- safety (quarantine) - choice

Oocyte cryopreservation

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In Italy from march 2004 to may 2009 (Law 40/2004)

we could only cryopreserve oocytes

Oocyte cryopreservation

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Lab outcomes: vitrification, infertile population

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Laboratory outcomes

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Cumulative ongoing pregnancy rates: vitrification

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Study design

o The study was design as a prospective longitudinal cohort study.

o The baseline characteristics, embryological data, clinical and ongoing pregnancy rate were analyzed on a per cycle basis.

o The cumulative pregnancy rate obtained with fresh and vitrified oocytes from the same stimulation cy- cle was analyzed on a per patient basis.

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Material & methods

o All consecutives patients undergoing ICSI treatment in the Centre for Reproductive Medicine GENERA between September 2nd 2008 and May 15th 2009 were considered for this study

o Only patients with supernumerary oocytes available for cryopreservation were included. A single fresh attempt was included for each patient

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69/120 = 57,5% ongoing pregnancy rate

Clinical results

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Embryo freezing: cumulative pregnancy rates

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Ubaldi et al., 2004

Embryo freezing: cumulative pregnancy rates

36%

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Cumulative pregnancy rate: <38 y. (Ubaldi, 2004)

Fresh ET Fresh+frozen

All patients (with frozen embryos) 232 232

Clinical preg. after fresh ET 113 113

Clinical preg. after 1°thawed ET - 33

Clinical preg. after 2°thawed ET - 10

Total clinical pregnancies 113 156

Cumulative clinical preg.rate/patient (%) 113/232 (48,7) 156/232 (67,2)

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Oocyte vitrification: cumultive ongoing pregnancy rates

69/120 = 57,5% ongoing pregnancy rate VS

<38 y: frozen embryos 156/232 = 67,2% clinical pregnancy rate

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In Italy from may 2009 (Supreme Court 151/2009)

we can also cryopreserve embryos

Oocyte cryopreservation

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Study design

• Retrospective observational study• All consecutives patients undergoing fresh ICSI treatment

where oocyte cryopreservation was performed (first period under the Law limitation: September 2008 – May 2009) and all consecutives patients undergoing fresh ICSI treatment where embryo cryopreservation was performed (second period without Law limitation: September 2009 – May 2010)

• Primary outcome: cumulative ongoing pregnancy rate obtained with fresh + vitrified oocytes (first period) or with fresh + vitrified embryos (second period). Warming cycles were included until December 2009 and December 2010, respectively

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Cryopreservation method

• Vitrification protocol : Kuwayama method (2005,2007)

• Cryoprotectants: 15% DMSO 15% EG

• Tool: Cryotop (open system)

Rienzi et al., Hum Reprod 2010

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Baseline patient’s characteristics

Oocyte Group Embryo Group p

No. patients 182 156

% of the stimulated patients 182/428 (42.5) 156/532 (29.3) P<0.0001

Mean age (mean+SD) 35.81±4.19 36,10±3,67 ns

Mean basal FSH (mean+SD) 6.5±2.2 6.75±2.6 ns

Agonist protocol (%) 143/182 (78.6) 108/156 (69.2) ns

Antagonist protocol (%) 39/182 (21.4) 48/156 (28.8) ns

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Fresh and warming cycles laboratory outcomes

Oocyte Group Embryo Group p

Fresh cycle: laboratory outcome

Inseminated MII (mean±SD) 2.9±0.4 6.2±2.0 P<0.000

2 PN (mean±SD) 2.6±0.6 5.1±1.8 P<0.000

Top quality embryos (mean±SD) 1.5±0.96 2.2±1.6 P<0.000

Embryo transferred (mean±SD) 2.5±0.6 2.2±0.8 P<0.002

Oocyte/embryo vitrified (mean±SD) 6.2±3.1 2.3±1.6 P<0.000

Warmed cycles: laboratory outcomes

Oocyte/embryo warmed (mean±SD) 4.2±1.2 2.1±0.8 P<0.000

Oocyte/embryo survived (mean±SD) 3.8±0.9 2.0±0.7 P<0.000

Inseminated MII (mean±SD) 2.9±0.2 -

2 PN (mean±SD) 2.5±0.6 -

Top quality embryos (mean±SD) 1.5±0.9 -

Embryo transfer (mean±SD) 2.4±0.8 2.0±0.7 P=0.03

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Fresh cycles: overall results

Oocyte Group Embryo Group p

No. of cycles 182 156

Mean age (M±SD) 35.81±4.19 36,10±3,67 nsNo. of ET 172 144

ET % 172/182 (94,5) 144/156 (92,3) ns

Clinical pregnancy rate per cycle 77/182 (42,3) 78/156 (50,0) ns

Clinical pregnancy rate per ET 77/172 (44,8) 78/144 (54,2) ns

Implantation rate % 101/435 (23,2) 111/342(32,4) P<0,004

Abortion rate % 9/77 (11,7) 9/78 (11,5) ns

N ongoing pregnancy fresh 68 69

Ongoing pregnancy rate per fresh cycle % 68/182 (37,4) 69/156 (44,2) ns

Ongoing implantation rate 90/435 (20,7) 101/342 (29,5) P<0,005

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Warmed cycles: overall results

Oocyte Group Embryo Group p

No. of cycles 115 78No. of ET 111 77ET % 111/115 (96,5) 77/78 (98,7) nsClinical pregnancy rate per cycle 35/115 (30,4) 21/78 (26,9) nsClinical pregnancy rate per ET 35/111 (31,5) 21/77 (27,2) nsImplantation rate % 43/266 (16,1) 22/156 (14,1) nsAbortion rate % 6/35 (17,1) 5/21 (23,8) nsN ongoing pregnancy vitrified 29 16Ongoing pregnancy rate per vitrified cycle % 29/115 (25,2) 16/78 (20,5) nsOngoing implantation rate 35/266 (13,2) 16/156 (10,2) ns

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Cumulative ongoing pregnancy rate after the fresh cycle, first

warming cycle and second warming cycle.

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Overall

Oocyte Embryo p

Fresh 68/182 (37.4) 69/156 (44.2) ns

I warming cycle 84/182 (51.6) 85/156 (54.5) ns

II warming cycle 97/182 (53.3) 85/156 (54.5) ns

Cumulative ongoing pregnancy rate after the fresh cycle, first and second warming cycle

N° of cycles per patient 1.63 1.50

509 oocytes and 178 embryos still available in the pregnant patient groups

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Cumulative ongoing pregnancy rate after the fresh cycle, first and second warming cycle according to female age

≤34 yrs 35-37 yrs 38-40 yrs 41-43 yrs

Oocyte Embryo Oocyte Embryo Oocyte Embryo Oocyte Embryo

Fresh cycle 29/72 (40.3) 29/57 (50.9) 20/48(41.7) 25/44 (56.8) 15/41(36.6) 13/43 (30.2) 4/21 (19.0) 2/12 (16.7)

I warming cycle 45/72 (62.5) 34/57 (59.6) 23/48 (47.9) 29/44 (65.9) 20/41(48.8) 18/43 (41.9) 6/21 (28.6) 4/12 (33.3)

II warming cycle 45/72 (62.5) 34/57 (59.6) 24/48 (50.0) 29/44 (65.9) 21/41 (51.2) 18/43 (41.9) 7/21 (33.3) 4/12 (33.3)

p = ns in any analyzed group

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Overall

Oocyte Embryo p

Fresh 90/435 (20.7) 101/342 (29.5) p = 0.005

Warming cycles 35/266 (13.1) 16/156 (10.2) ns

Fresh+ warming(cumulative) 128/701 (17.8) 117/498 (23.5) p = 0.03

Cumulative ongoing implantation rate after fresh and warming cycle

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Conclusion

In this study we have compared two different policies applied on the general infertile population:

- limited number of inseminated oocytes and oocyte cryopreser- vation

- higher number of inseminated oocytes and embryo cryopreser- vation

Same vitrification approach was used in both groups.

According to our results when embryo selection is possible a significantly higher ongoing implantation rate can be achieved in the fresh cycle.

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Conclusion

• The cumulative ongoing pregnancy rate is similar in both groups when including the warming cycles. The cumulative ongoing implantation rate is higher in the frozen embryo group

• Slightly more transfers are necessary in the oocyte group as compared to the embryo group to reach the same results

• With oocyte cryopreservation no supernumerary embryos are created (only oocytes with no related ethical and moral issues)

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Conclusion

• Although the limits of the study design, with oocyte cryopreservation it is possible to achieve good cumulative clinical results in a standard infertility population

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• A prospective randomized trial is needed to assess the efficacy of oocyte vs embryo cryopreservation

CLINICA VALLE GIULIA, Roma

SALUS, Marostica (VI)

GENERA, Umbertide (PG)

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Ginecologia:

Filippo Ubaldi

Elena Baroni

Antonio Ciconte

Silvia Colamaria

Fabrizio Fiorini

A. Giallonardo

Madda Giuliani

Fabio Sapienza

Mauro Schimberni

Silvia Venanzi

Embriologia:Laura Rienzi

Stefania Romano

Roberta Maggiulli

Laura Albricci

Antonio Capalbo

Nicoletta Barnocchi

Benedetta Iussig

Sara Fusco

Federica Sanges

Catello Scarica

Elena Ievoli