Clinical Trial Details
— Status: Completed
Administrative data
| NCT number |
NCT03915054 |
| Other study ID # |
CS/BVMD/19/03 |
| Secondary ID |
|
| Status |
Completed |
| Phase |
N/A
|
| First received |
|
| Last updated |
|
| Start date |
April 17, 2019 |
| Est. completion date |
January 31, 2020 |
Study information
| Verified date |
June 2021 |
| Source |
M? Ð?c Hospital |
| Contact |
n/a |
| Is FDA regulated |
No |
| Health authority |
|
| Study type |
Interventional
|
Clinical Trial Summary
Clinical use of IVM was pioneered in the nineties, but has not yet become a realistic option
for wide-scale practice, for several reasons. Fundamentally, despite recent progress in
improving the implantation and the pregnancy rates using in-vitro matured oocytes, results of
IVM remain lower than treatment cycles utilizing conventional ART. To improve the outcome of
IVM cycles, this study focuses on improving in-vitro culture conditions.
In-vitro maturation (IVM) of human oocytes obtained from minimally stimulated or unstimulated
ovaries offers a more "patient friendly" treatment option than the conventional Assisted
Reproductive Technology (ART) treatment with controlled ovarian hyperstimulation (COH).
Typically, IVM will be offered to women with polycystic ovaries (PCO/PCOS), or to patients
with an excellent ovarian reserve, i.e. a high antral follicle count. IVM treatment is
characterized by minimal administration of FSH or hMG and NO hCG trigger. The IVM approach is
less disruptive to patients' daily life through the reduced need for hormonal and ultrasound
monitoring, avoids a range of minor and major complications, such as ovarian hyperstimulation
syndrome, and aims to reduce the total cost of infertility treatment for the patient and for
the health care budget.
Human oocytes retrieved from small antral follicles are able to resume meiosis by undergoing
germinal vesicle breakdown and extrusion of the first polar body, if oocytes have reached
meiotic competence. These oocytes can be fertilized although only a proportion (less than
50%) of them can develop further into viable embryos. It has been hypothesized that failure
of embryonic development may, at least in part, be due to an immature oocyte cytoplasm. A
novel human in vitro maturation (IVM) culture system (named CAPACITATION-IVM is being
investigated, hereafter named "CAPA") using 1°) natural compounds known to influence cAMP
levels within the cumulus-oocyte-complex and 2°) compounds that are crucial for the
oocyte-cumulus cross-talk. Keeping cyclic AMP high after retrieval in the GV oocyte prevents
the occurrence of nuclear maturation, enabling increased communication between the oocyte and
the cumulus cells. This allows for the improvement in the synchronization of nuclear and
cytoplasmic maturation processes in the oocyte, to the benefit of embryo quality.
Description:
There are two types of patients can be distinguished in this study:
- Polycystic ovarian morphology + normal cycle length (up to 35 days). The majority of
subjects in this group have non-syndromic polycystic ovaries and do not have PCOS. In
these patients, AMH is only moderately elevated and cyclical follicular development
occurs under the influence of FSH.
- PCOS - Polycystic ovarian morphology + oligomenorrhoea (menstrual periods occurring at
intervals of greater than 35 days, with only four to nine periods in a year) or
amenorrhea. In these patients, with often strongly elevated AMH levels and concomitant
hyperandrogenemia, relative FSH resistance results in arrest of follicular growth at the
small antral follicular state. Spontaneous selection of a dominant follicle does not
occur or occurs rarely. A large proportion of follicles are atretic. An important
proportion of these patients have a BMI higher than 25. These patients generally receive
the same standard gonadotropin stimulation regimen as the patients of the previous
group, but if the largest follicles have a diameter of less than 8 mm on the third day
of stimulation, patients receive one or two supplementary days of gonadotropin
stimulation. Moreover, these patients generally take two-three weeks of OCP before the
start of the IVM cycle and start stimulation approximately on day five after OCP
withdrawal. However, since these patients do not have endogenous FSH-driven recruitment
of follicles, the start of stimulation is rather flexible.
- The use of OCP (oral contraceptive pill) before the IVM cycle is obligate. OCP (for
example Microgynon 30 micrograms) will be administered daily, to clear the atretic
follicles in the ovary. OCP will be given for between 14 and 21 days (this method allows
for better programming the cycles and the workload in the embryology lab).
Before the first IVM cycle (Screening visit): All subjects will undergo a pelvic ultrasound
scan to evaluate suitability to undergo IVM treatment. Patients will undergo a blood test for
serology (Hepatitis B, HIV, syphilis) and baseline hormonal profiling (LH, FSH, E2,
progesterone, AMH, SHBG, Testosterone). Additional analysis of TSH, thyroperoxidase
antibodies, prolactin. Any concomitant medication taken in the last 3 months prior to the IVM
attempt should be notified.
First IVM treatment cycle:
- First clinic visit:
- All subjects will contact the study nurse on cycle day (cd1) to initiate the first
Capacitation culture cycle. If cd1 is during the weekend, subjects will contact the
study nurse on Monday. The subject will attend the clinic on day 1, 2 or 3 of
menstrual bleeding. An ultrasound scan is performed to rule out the existence of
ovarian cysts and a blood sample is taken for hormonal assessment (HCG, FSH, LH,
E2, progesterone). On the evening of cycle day 3 of the first clinic visit,
flexible Gonadotrophin stimulation will be started to enhance follicular
development. The first dose of HP-hMG 150 IU at 2 PM. Second dose next day of
HP-hMG 150 IU at 2 PM. The subject will return for a pelvic ultrasound scan and a
blood test (FSH, LH, E2, progesterone) after the two days of HP-hMG 150 IU
stimulation (i.e. on the morning of day 6).
- To patients with OCP bleeding: On day one, two, three, or four of the withdrawal
bleeding that occurs after discontinuing the OCP, the subject will attend the
clinic to undergo a pelvic ultrasound scan and a blood sample is taken for hormonal
assessment (FSH, LH, E2, progesterone, AMH, total serum testosterone, SHBG). On the
day of the first clinic visit, flexible HP-hMG stimulation will be started to
enhance follicular development, at a first daily dose of HP-hMG at 8 P.M. The
subject will return for a pelvic ultrasound scan and a blood test (FSH, LH, E2,
progesterone) after two days of HP hMG stimulation.
- Second clinic visit at day 6 (after 2 days of HP-hMG treatment):
- If the ultrasound scan shows the presence of a single dominant follicle larger than
12 mm with the other follicles all less than 10 mm, and the oocyte retrieval (OR)
will be scheduled two days later, between 8:00 and 9:00 h. It is important to keep
the OR 42 - 46 hours after the last HP-hMG injection as a fixed timing. If the
ultrasound scan shows a maximal follicular diameter of less than 8 mm, a final
injection of HP-hMG will be administered at 2 P.M. and the oocyte retrieval (OR)
will be scheduled two days later, between 8:00 and 9:00 h. It is important to keep
the OR 42 - 46 hours after the last HP-hMG injection as a fixed timing.
- To patients with OCP bleeding: If the ultrasound scan shows a maximal follicular
diameter of approx. 9 mm, a final injection of HP-hMG will be administered at 2
P.M. and the oocyte retrieval (OR) will be scheduled two days later, between 8:00
and 9:00 h (under general anesthetics - the exact time of OR should be discussed
with operating nurses and anesthetist). It is important to keep the time of OR
constant at 42 -46 hours after the last HP-hMG injection.
- Third visit - Oocyte retrieval: Oocyte retrieval (OR) will be scheduled between 8:00 and
10:00 h (under general anesthetics). On the day of OR:
- An ultrasound scan of both ovaries and of endometrial lining is recorded.
- A blood sample will be obtained for hormonal profiling (LH, FSH, E2, progesterone).
- All cumulus-oocyte complexes (COC) retrieved from the patient are cultured in CAPA
medium for 24 hours.
- Following CAPA culture, half of oocytes will be divided randomly (50/50) to the two
maturation triggers medium.
- Group 1: Medicult IVM media + AREG+FSH+HSA+Insulin+Estradiol (AREG-TRIGGER group)
- Group 2: Medicult IVM media + FSH+GH+hCG+HSA (CONTROL-TRIGGER group) with no AREG
added
- In vitro oocyte maturation:
- Evaluate and register COCs for cumulus mass (CM) and cumulus contact between oocyte
and cumulus cells. Each time take photographs. Discard fully denuded, degenerated
oocytes.
- Transfer half of the COCs (5-10 at a time) from the Capacitation culture dish to
the "washing dish" containing "Maturation Medium 1 (AREG-TRIGGER medium)" by using
an Eppendorf micropipette and wash them thoroughly (load pipette tips with 5µl,
max. 10µl). Then transfer COCs to the "IVM dish" with "Maturation Medium 1
(AREG-TRIGGER medium)".
- Transfer the second half of the COCs from the Capacitation culture dish to the
"washing dish" containing "Maturation Medium 2 (CONTROL-TRIGGER medium)" and wash
them thoroughly (load pipette tips with 5µl, max. 10µl). Then transfer COCs to the
"IVM dish" with "Maturation Medium 2 (CONTROL-TRIGGER medium)".
- Keep COCs in pools of ~10.
- Label the dish appropriately and culture COCs 30-32 hours in an incubator.
- Evaluation of maturation (MII, GVBD, GV) will be done at 30 hours. Oocytes which have
undergone GVBD but with no clear PB will be assessed at 32 hours. Insemination will be
performed using intra-cytoplasmic sperm injection (3-4 hours after oocyte retrieval or
maturation check); only matured oocytes will be inseminated.
- Fertilization check will be performed under an inverted microscope at 16-18 hours after
insemination. Embryo evaluation will be performed at 68 ±1 hours after fertilization
using the Istanbul consensus. Standard Embryo Vitrification protocol used. Embryos will
be vitrified per stimulation protocol obtained (group 1 AREG-TRIGGER or group 2 -
CONTROL-TRIGGER).
- Frozen embryo transfer: The patient will be randomized to receive embryo randomly from
AREG-TRIGGER or CONTROL-TRIGGER. Where no embryo(s) from the randomized group were
available, embryo(s) from the other group were transferred.
- The first pregnancy test was performed 14 days after embryo transfer; a positive
pregnancy test was defined as serum beta hCG >5 mIU/mL
- Clinical pregnancy was defined as at least one gestational sac on ultrasound at 7 weeks'
gestation with the detection of heartbeat activity.
- Ongoing pregnancy was defined as pregnancy with a detectable heart rate at ≥12 weeks'
gestation after the completion of the first transfer.
- Live birth was defined as the birth of at least one newborn after 24 weeks' gestation
exhibiting any sign of life (twins were a single count).
- After a first unsuccessful IVM cycle: The clinical and embryological data and results
related to the first IVM cycle (cumulative fresh and frozen embryo cycles) will be
discussed, to establish a more patient-tailored approach for an eventual second IVM
cycle. The patient-tailored approach in the second IVM cycle might consist of
modification of the management of the follicular phase.
