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

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

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

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

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

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

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

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

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)

Ultrasound Exam Antral follicle count Uterine fibroid (circled) and polyp (arrow) ?Frequency in EDS? Antral follicle count Assessment of ovarian “aging” ?Altered in EDS? http://www.advancedfertility.com/pics/antralnormal2.jpg

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

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

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

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

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 24-36 hours after HCG Carolinas Medical Center Protocol

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

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

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

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

IVF and Age: Birth Rates SART 2009 National Data <35 41% 35-37 32% 38-40 22% 41-42 13% 43-44 4% SART 2009 data

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

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

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

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

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

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)

Trophectoderm Biopsy Carolinas Medical Center Trophectoderm cells: develop into placenta

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

Polar Body Biopsy Diagnose before fertilization without discarding embryo

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

PGS Sample Outcome Missing Chromosome 5 Normal Chromosomes Complex Abnormal

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

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

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

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) 355-3149; bhurst@carolinas.org