Université Paris-Descartes, Hôpital Cochin, Paris, France
The taming of the shrewLow-risk ART for the high-risk woman
Charlers Chapron Bruno Borghese Hervé Foulot Antoine Bouret Paul Mazurk Guillaume Pierre Marie Christine Lafay Fouzia Decupere François X. Aubriot
Dominique de Ziegler Vanessa Gayet Pietro Santulli
Paul Pirtea Blandine Boquet Aurélie Vincent
Bander Kuttbi François Aubriot
Ann Marszalek
The taming of the shrewLow-risk ART for the high-risk woman
Problem: Hazards different from expected
➢ART with COS, wed from incept ➢Hazard of COS seen in:
• Multiple follicle • High E2 • Retrievals w/ OMA
The taming of the shrewLow-risk ART for the high-risk woman
Problem: Hazards different from expected
➢ART with COS, wed from incept ➢Hazard of COS seen in:
• Multiple follicle • High E2 • Retrievals w/ OMA
ovulation Controlled Ovarian Stimulation (COS)
Howard W. Jones Jr. MD The Jones Institute Norfolk, VARobert G.
Edwards, PhD.
The taming of the shrewLow-risk ART for the high-risk woman
C O S
The single most effective measure ever taken for enhancing ART
outcome
ART and COS: Wed from incept
ovulation Controlled Ovarian Stimulation (COS)
Hazard of ART: COS
1. Multiple Follicles
2. High E2 levels
Robert G. Edwards, PhD.
The taming of the shrewLow-risk ART for the high-risk woman
Howard W. Jones Jr. MD The Jones Institute Norfolk, VA
C O SART and COS:
Wed from incept
The taming of the shrewLow-risk ART for the high-risk woman
Problem: Hazards different from expected
➢ART with COS, wed from incept ➢Hazard of COS seen in:
• Multiple follicle • High E2 • Retrievals w/ OMA
ART and COS: Wed from incept
The taming of the shrewLow-risk ART for the high-risk woman
Hazard
Risk
Risk mitigationBuilding your
defenses
ART and COS: Wed from incept
The taming of the shrewLow-risk ART for the high-risk woman
‘potential source of danger’
‘Unpleasant event
happening’
Building your
defenses
Hazard
Risk
Risk mitigation
The taming of the shrewLow-risk ART for the high-risk woman
Risk1. OHSS 2. VTE 3. TOA
Hazards identified1. Multiple follicle 2. High E2 3. Retrieval w/ OMA
Problem: Hazards different from expected
The taming of the shrewLow-risk ART for the high-risk woman
Risk1. OHSS 2. VTE 3. TOA
Hazards identified1. Multiple follicle 2. High E2 3. Retrieval w/ OMA
Problem: Hazards different from expected
Defense1. Low Stim 2. Dx, Hep 3. TOA
Bart Fauser Paul Devroey Sam Yen Roger Gosden Bill Crowley David Baird Phil Bouchard
Minimal ovarian stimulation for
IVF
A C O S F O R A L L S E A S O N S
Low-risk ART for high-risk patients: be safe, not sorryOHSS
Bart Fauser Paul Devroey Sam Yen Roger Gosden Bill Crowley David Baird Phil Bouchard
Minimal ovarian stimulation for
IVF
A C O S F O R A L L S E A S O N S
Low-risk ART for high-risk patients: be safe, not sorryOHSS
The taming of the shrewLow-risk ART for the high-risk woman
VTE
Effects of E2 on existing risks
VTE: identify patients at increased risk
The taming of the shrewLow-risk ART for the high-risk woman
VTE
obesity OC useVTE: identify patients at increased risk
Effects of E2 on existing risks
The taming of the shrewLow-risk ART for the high-risk womanVTE: identify patients at increased risk
VTE
The taming of the shrewLow-risk ART for the high-risk woman
Risk1. OHSS 2. VTE
1. Multiple follicle 2. High E2 3. Retrieval w/ OMA
Problem: Hazards different from expected
Primary Hazards
The taming of the shrewLow-risk ART for the high-risk woman
Risk1. OHSS 2. VTE
1. Effects of hCGon ov follicles
Problem: Hazards different from expected
Primary Hazard
The taming of the shrewLow-risk ART for the high-risk woman
Risk1. OHSS 2. VTE
Problem: Hazards different from expected
Defense
‘no-hCG’ ART
The taming of the shrewLow-risk ART for the high-risk woman
Risk1. OHSS 2. VTE 3. TOA
Problem: Hazards different from expected
1. Effects of hCGon ov follicles
2. Retrievals w/ OMA
Primary Hazards
OMA & TOA
Bowel injuryUrethral injuryBleeding requiring surgery
Retro-peritoneal hematom
a
Sx for ruptured endometriom
a
Infection TOA
The taming of the shrewLow-risk ART for the high-risk woman
TOA: Personal experience of
approx. 300 participants
SBA ART meeting:
20%
OMA & TOA
Spont n=6
ART n=3
OB n=2
The taming of the shrewLow-risk ART for the high-risk woman
11 c
ases
of
acut
e PI
D-TO
A
w/ OMAs
OMA & TOA
Spont n=6
ART n=3
OB n=2
The taming of the shrewLow-risk ART for the high-risk woman
11 c
ases
of
acut
e PI
D-TO
A
w/ OMAs
In ART with OMA, risk of TOA is under and over reported
TOA requires prompt laparoscopy for drainage and AB therapy
OMA & TOA
Hazards different from expectedThe taming of the shrewLow-risk ART for the high-risk woman
➢ Hazards of COS: 1. Effects of hCG: OHSS, VTE (in part)
2. Risk of TOA: OMA-related w/ and w/o ART
Defense against hCG hazards: ➢ Low-risk ‘no-hCG’ ART exists ➢ Learn how to manage OMA-related TOA
Early laparoscopy exploration and drainage
Hazards redefined
New thinkin
g
-
The deferred ET option (Def-ET)
The bottle neck of ART
COS
The GnRH trigger option
The taming of the shrewLow-risk ART for the high-risk woman
no hCG
‘no-hCG’ ART
Antagonist
0
12,5
25
37,5
50
oPR (%/1st ET)
Def-ET
Age &rank matched
Age matched rank 1
The taming of the shrewLow-risk ART for the high-risk woman
p = NS
p <0.05
‘no-hCG’ ART
The taming of the shrewLow-risk ART for the high-risk woman
3rd sector➢ Ascites ➢wt gain
HemocontrationVTE risk
tran
suda
te
hCG VEGF
Small foll
Hazards: different from expected, now redefined
Conclusio
n
OHSS
ART and COS: Wed from incept
The taming of the shrewLow-risk ART for the high-risk woman
3rd sector➢ Ascites ➢wt gain
HemocontrationVTE risk
tran
suda
te
hCG VEGF
Small foll
Low-risk ‘no-hCG’ ART for the high-risk patient exists
Conclusio
n
ART and COS: Wed from incept
The taming of the shrewLow-risk ART for the high-risk woman
3rd sector➢ Ascites ➢wt gain
HemocontrationVTE risk
tran
suda
te
hCG VEGF
Small foll
Low-risk ‘no-hCG’ ART for the high-risk patient exists
Conclusio
n
Low-risk ‘no-hCG’ ART:➢ Exists and is efficient➢ Practically eliminates OHSS➢ VTE: Eliminates the
hemoconcentration hazard
➢ VTE: Respective roles of high E2 and hemoconcentration need to be further determined
ART and COS: Wed from incept
‘no-hCG’ ART tames the COS-related risks of ART
Charlers Chapron Bruno Borghese Hervé Foulot Antoine Bouret Paul Mazurk Guillaume Pierre Marie Christine Lafay Fouzia Decupere François X. Aubriot
Dominique de Ziegler Vanessa Gayet Pietro Santulli
Paul Pirtea Blandine Boquet Aurélie Vincent
Bander Kuttbi François Aubriot
Ann Marszalek
Université Paris-Descartes, Hôpital Cochin, Paris, France
The taming of the shrewLow-risk ART for the high-risk woman
Conclusio
n
ART and COS: Wed from incept
‘no-hC
G’ ART
:
eliminate
s a haz
ard
& tames t
he spou
se of ART
,
COS