1. Ehlers-Danlos Syndrome Fertility Issues
Baltimore Inner Harbor
Independence Day
Brad Hurst, M.D.
Professor Reproductive Endocrinology
Carolinas Medical Center - Charlotte, North Carolina

2. Objectives Determine if EDS causes infertility
Describe infertility evaluation
Discuss cost-effective infertility treatment
Consider role of IVF
Learn new approaches to preimplantation genetic diagnosis that may apply to EDS

3. Ehlers-Danlos National Foundation 1994
68 women, most type I, III, IV
43 women, 138 pregnancies
Reproductive problems:
Spontaneous abortion 29% (40/138)
25% all pregnancies in population
Sexual dysfunction (61%)
43% prevalence women
Irregular menses (28%)
11% college-age population
Endometriosis (16%)
5-10% population
Sorokin Y. et al, J Reprod Medi 39:281-4, 1994

4. Endometriosis/dyspareunia 1995
41 women in Ehlers-Danlos clinic
Endometriosis 27%
5-10% population
Painful intercourse 57%
45% population
Gynecologic disorders in women with Ehlers-Danlos syndrome.
McIntosh LJ et al, J Soc Gynecol Invest 2:559-64, 1995

5. Ehlers-Danlos Fertility Publications Since 1995
In vitro fertilization (IVF) - none
Ovulation - none
Pelvic pain - none
Endometriosis - none
Dyspareunia - none
Amenorrhea - none
Oligomenorrhea - none
Ectopic pregnancy - none
Preimplantation genetic diagnosis - none
Insemination - none
Sperm/spermatozoa - none
Oocyte - none
Clomiphene - none
Fallopian tube - none
Medline search June 2011

6. Ehlers-Danlos and Fertility Assumptions
Women with Ehlers-Danlos experience infertility
Infertility prevalence
1 in 8 couples in population
More ovulation disorders, endometriosis, painful intercourse, miscarriage with EDS
Some women with Ehlers-Danlos may be advised to avoid pregnancy
Vascular, maybe kyphoscoliotic type
But some may still want to have children!
Esaka EJ et al, Obstet Gynecol 113:515-8, 2009
Volkov N et al, Obstet Gynecol Surv 62:51-7, 2007

7. What is Infertility?
“Infertility is a disease, defined by the failure to achieve pregnancy after 12 months or more of regular unprotected intercourse.”
Women ≥ 35 years old: evaluation justified after 6 months of unprotected intercourse
Earlier evaluation for
Infrequent menses
Known tubal disease or endometriosis
Known male infertility
ASRM Practice Committee 2008

8. Example: What is appropriate evaluation?
33 year-old never pregnant EDS
(non-vascular)
Unprotected intercourse 2 years, 2-3 X per week
Regular cycles 28 days with premenstrual breast soreness
Healthy, rest of history normal

9. Infertility: 5 Key Tests
Confirm ovulation
History most important
Assess uterus and fallopian tubes
Hysterosalpingogram
Assess male fertility
Semen analysis
Assess uterus and ovaries
Ultrasound
Assess ovarian aging
Day 3 FSH and Estradiol (blood test)
AMH level (blood test)

10. Ultrasound Exam Antral follicle count Uterine fibroid (circled)
and polyp (arrow)
?Frequency in EDS?
Antral follicle count
Assessment of ovarian “aging”
?Altered in EDS?

11. Diagnosis of Polycystic Ovarian Syndrome (2 of 3 required) Most common cause of irregular cycles; More common with EDS?
Irregular, infrequent cycles
Excessive male hormone
Hirsutism
Laboratory tests
Ultrasound appearance
≥12 follicles
ESHRE/ASRM 2003 Consensus

12. 33 y.o. Evaluation Negative What Would You Recommend?
Just give her more time – she’s only 33
Clomiphene
fertility med
Clomiphene plus insemination
IVF
A Procreation Vacation

13. Answer: Evaluation Negative What Would You Recommend?
Just give her more time – she’s only 33
Clomiphene
Clomiphene plus insemination
IVF
A Procreation Vacation

14. Unexplained Infertility Treatment Outcomes
Cycle pregnancy rate:
Timed intercourse 3-4%
Clomiphene + intercourse 5-8%
Clomiphene + IUI 10-15%
Superovulation (FSH/HMG) + IUI 15-20%
IVF: 41% live birth rate/cycle start
Age < 35
SART.ORG

15. Clomiphene with Insemination Unexplained Infertility
Clomiphene 50 mg days 5-9
Ultrasound day 11-13
HCG when follicle mature
Ovulation occurs ~ 36 hours after HCG
Intercourse day of HCG
Insemination hours after HCG
Carolinas Medical Center Protocol

16. 33 y.o. non-vascular EDS, completed clomid+IUI X 3
What is the most cost effective treatment?
Continue clomiphene + IUI for 6 cycles
Fertility injections + insemination
IVF
Surgery (laparoscopy) to assess/treat endometriosis

17. 33 y.o. non-vascular EDS, completed clomid+IUI X 3
What is the most cost effective treatment?
Continue clomiphene + IUI for 6 cycles
Fertility injections + insemination
IVF
Surgery (laparoscopy) to assess/treat endometriosis

18. In Vitro Fertilization and Embryo Transfer (IVF-ET)
Steps:
Ovarian Stimulation
Oocyte retrieval
Insemination/ICSI
Lab fertilization and embryo culture
Embryo transfer

19. IVF Laboratory Insemination day of retrieval
Day 1:  70% mature oocytes fertilize (2 pronuclei seen)
Day 2: 4 cell
Day 3: 8 cell
Day 4: morula
Day 5: blastocyst

20. IVF and Age: Birth Rates SART 2009 National Data
< % % % % %
SART 2009 data

21. Embryo Freezing with IVF
Freeze excess healthy embryos
Avoids discarding healthy embryos
Lower cost, simpler than IVF
Birth rate
35% per embryo transfer
SART 2009 data

22. How to interpret a SART Report for Single Embryo Transfer
Fresh Embryos From Non-Donor Oocytes
<35
35-37
38-40
41-42
Number of cycles 80 39 40 7
Percentage of cycles resulting in pregnancies
51.2
46.2
62.5
0 / 7
Percentage of cycles resulting in live births
42.5
38.5
Percentage of retrievals resulting in live births
39.5
0 / 6
Percentage of transfers resulting in live births
43.6
0 / 5
Percentage of cancellations
2.6
1 / 7
Implantation rate
30.6
25.0
26.5
0 / 17
Average number of embryos transferred
2.0
2.2 3
3.4
Percentage of live births with twins
29.4
3 / 15
6 / 17
Carolinas Medical Center 2009 SART Report

23. ART High-Tech Innovation: Application to Ehlers-Danlos
Elective single embryo transfer
Important to avoid twins with EDS due to risk of preterm labor/delivery
Preimplantation genetic screening/diagnosis
Limit twins/multiple pregnancies
Minimize risk with Vascular and Kyphoscoliosis EDS
Potential transfer of non-affected embryos to carrier
Reduce miscarriage

24. Preimplantation Genetic Diagnosis Day 3 Embryo Biopsy
PCR (1st case 1990)
Single gene defects
X-linked disorders
FISH
Chromosomal abnormalities
X-linked diseases
>50% embryos have
abnormal # chromosomes
Munne S, et al. Reprod Biomed Online 20:92-7, 2010

25. Limitations of Day 3 Biopsy
Never improved pregnancy rates
Possibly due to embryo damage
Lowered miscarriage rate by ~ 50%
Did not test for all 46 chromosomes
Cleaving embryos can be mosaic on day 3
Abnormal FISH with normal embryo
Abnormal embryo with normal FISH
Can’t screen for chromosome # (FISH) and gene disorder (PCR)
Important to do both with EDS
Day 3 biopsy role now limited!
Mosaic Fish

26. New Preimplantation Testing Trophectoderm biopsy with CGH
Trophectoderm – cells that will become placental cells in a day 5 embryo
CGH
Microarray Comparative Genomic Hybridization
Determine if the correct # chromosomes are present in the embryo
Screen for gene disorders
(ex: COL3A1 gene – vascular type)

27. Trophectoderm Biopsy Carolinas Medical Center
Trophectoderm cells: develop into placenta

28. Trophectoderm Biopsy More cells for testing (4-10)
Screen “proven” embryos only (blastocysts)
Transfer embryos with 46 chromosomes
Pregnancy rates ~ 75%+ for single embryo transfer
Screen for gene abnormalities (ex: COL3A1gene)
Disadvantages:
Requires high technical proficiency
Freeze embryos while awaiting test results
Delayed transfer of frozen embryos

29. Polar Body Biopsy
Diagnose before fertilization without discarding embryo

30. High Tech Application for EDS: Potential Case
31 year-old Vascular-type EDS
Advised to avoid pregnancy
Having children is lifelong dream/expectation
Considering IVF with gestational carrier
Problems:
Risk associated with ovarian stimulation with EDS vascular type
Cost of gestational carrier
Birth rate ~ 40-50% at age 31 (~ 50% have 46 chromosomes)
Transfer multiple embryos? Increased risk for carrier!!!
50% risk of transmitting EDS vascular type to offspring
Solution: PGD, freeze embryos, single FET of unaffected embryo with normal number of chromosomes to carrier

31. PGS Sample Outcome Missing Chromosome 5 Normal Chromosomes
Complex Abnormal

32. CMC 2011 Applications for Trophectoderm Biopsy / PGD
Expected large cohort of frozen embryos
Recurrent pregnancy losses
Single gene disorders
Elective single embryo transfer
Repeated implantation failures
Polar body or blastocyst biopsy
Application for gestational carrier
Fertilize, blastocyst biopsy, PGD, freeze
Allows single embryo transfer to gestational carrier
If chromosome number is correct, maternal age is irrelevant

33. Infertility Surgery with Ehlers-Danlos: Special Considerations
Difficult intubation/airway
Post-operative hernia
Laparoscopy when possible!
Laparoscopic Myomectomy
for uterine fibroids
Hurst BS et al, Fertil Steril 2005

34. Endometriosis Infertility Laparoscopy
Surgery required for large endometriosis cysts
Treatment Stage I / II endometriosis:
↑ preg rate 1-2% / month
Long-term success (stage I / II)
35-70%
Risks:
surgery
delay treatment

35. Conclusions Probable higher incidence infertility with Ehlers-Danlos
Better data needed. Please complete ANONYMOUS Survey Monkey Survey!!!
Early IVF with single embryo transfer often best option for infertile women with EDS
PGS/PGD improves embryo selection and efficiency of IVF, especially for single embryo transfer
Gestational carrier for vascular and kyphoscoliosis-type EDS; PGD advisable
If surgery, laparoscopy!
Contact: Brad Hurst, M.D., Carolinas Medical Center, Charlotte (704) ;