In this webinar, Dr Uliana Dorofeyeva, Director of International Cooperations at IVMED, Ukraine, and a Medical Director at OVOGENE Egg Donor Bank, has explained the genetics of premature & early menopause.
We’re going to talk about earlier menopause and genetic background but before moving on, let’s start from the beginning. The beginning is understanding our resources and the most valuable resource for women is our ovarian reserve, even before a girl is born it’s already predicted how many follicles she will have, how many years of ovulation and menstruation she will get, what will be her response, what will be her antral follicle count, and what will be her AMH during every period of her life.
You can see the graph of the maximum number of antral follicles during the antenatal period of growth of the fetus and before the delivery we’re getting lower numbers, and we deliver the fetus with a certain number of antral follicles which is about two million.
During the period of puberty, until puberty and the first menstrual period, there is a certain classification of every girl who is getting into her puberty regarding the potential and number of her antral follicle count, and we are left with about four hundred thousand to five hundred thousand antral follicles on a different level of their growth.
During the fertile period, which is usually starting from 11 and up to 50 on average years old, we have about 400 to 500 menstrual cycles. We’re producing between 400 and 500 oocytes which are getting into the mature stage, so they’re getting into the stage of ovulation. This is the potential number of those who might be fertilized, who might produce embryos, and who might be used for fertility treatment.
We need to understand that 99.9 of our follicles are lost because during every menstrual cycle, at the beginning of the follicular phase, our ovaries recruit a certain number of follicles, depending on which ovarian reserve we have in this specific term of our development. If we are in our 20s, the normal ovarian reserve for every cycle in terms of the number of antral follicles would be between 20 to even 50 and 60, meaning that these are follicles in their class 2 or class 3 of their growth which can be recruited, which are already sensitive to FSH, and they can potentially grow if they receive enough FSH.
However, because our hypothesis is producing very low numbers of FSH, only one follicle in the natural cycle will be recruited, and all others from those 20 to 50 in young ages will be in the stages of being able to be potentially recruited, but if they don’t receive enough FSH, they will just get into atresia, meaning we will lose them and never again will it be possible to use them again. If we are already in our 30s, the number of antral follicles will be less, it will be between 10 and 30 on average, but still, every menstrual cycle we will be recruiting this number of follicles, and we will either use them or not.
If we are moving to our 40s, we all understand that there is a decrease in the total number of antral follicles, meaning that in every cycle, the potential recruitment will be less but still, there is potential recruitment. If you are moving into the process of menopause, and we go back to your period of life, we will talk about age, but still, we can recruit, we can produce some amount of follicles, but this amount is very low.
This is an age-dependent permanent cessation of menstruation and ovulation due to ovarian failure. This is a physiologic process, but it depends on which period, of our age, this is happening.
This is also diagnosed after 12 months without a menstrual period. It’s very important to have a definition of menopause because many patients, start to get irregular menstrual cycles, or they are missing one or two cycles, or they have a delay in their next cycle to come, and they are in their older age, they think they are already in menopause, but this is not true. This is a different period, and you have menopause only if you have no menstruation during your 12 months.
The median age of natural menopause varies according to the ethnic group, genetic, demographic, socioeconomic, dietary, drug reproductive, and different behaviours.
The international range of age of natural menopausal is between 44.6 to 55 years, and it’s quite variable worldwide. Some scientific publications have been reporting that the age of natural menopause is the following:
It’s very significant to understand these changes in women’s health because the fertility changes and the hormonal regulations are very associated with the somatic standards. Moreover, the health wellness regarding early or late menopause, if we can control, predict, or take care of this, we can reduce the risk of chronic diseases that will reflect the health of our society and patients.
Here you can see the distribution of the age of menopause, and you can see that it’s mainly happening after 45 with the middle average age between 51-52, but there is a condition that is earlier than 40 years old, some patients are getting to menopause. We also call this a specific disease, a premature ovarian failure.
We can see the changes mainly in hormonal production, in endocrine production mainly, and the most important predictor right now is the Anti-müllerian hormone (AMH), also FSH, LH, Inhibin, Estradiol, and more.
Now, we’re talking more and more about genes. Recent genome-wide association studies have identified over 44 genetic variants of genes which are associated with age of onset of natural menopause.
Moreover, genes linked with menopause can be classified into three major groups:
Biological and epidemiological logical data indicate that reproductive performance, age of menopause, and longevity are interlinked through common genetic factors which play a pivotal role in DNA repair and genome maintenance, which have been linked before the process of ageing, meaning that again we are talking that the somatic status and somatic health are also responsible for failure to reproduce and subsequent occurrence of menopause.
In addition, the reproductive performance may be strongly linked to the physical condition of the woman and may be a very good predictor of general health in the later life of the patient.
If the menopause starts before 40, we call this premature menopause or Premature Ovarian Insufficiency. If menopause is detected between 40 and 45 years old, we call this early menopause.
The stage when we have irregular menses within the last 12 months or the absence of menstrual bleeding for more than three months but less than 12 months, we call this perimenopausal stage. This is a stage when many changes are happening and this is the time when we need to take responsibility to be checked by our doctor, not only by gynaecologists but also endocrinologists. The gynaecologist will refer you to the specific doctors whom you also need to be checked.
Before the age of natural menopause occurs, the hormone estradiol becomes insufficient. The latter is primarily due to follicle ageing leading to ovarian failure or secondary due to granulosa cell apoptosis or epigenetic factors. AMH is also a predictive factor.
You can see the graph showing a green sector which is the optimal Anti-Mullerian Hormone and red which is already decreased. For some patients, we can talk about young patients, AMH can be very high for those, for example, PCOS patients. Early menopause can be reported to be associated with a higher risk of cardiovascular diseases, all-cause mortality, and osteoporosis.
On the other hand, late menopause has been associated with the increased risk of breast cancer, endometrial and ovarian cancer, so identifying the link factors of menopausal age among postmenopausal women, especially those who are amendable, may help prevent morbidity and mortality for women.
How do we connect AMH level with the period when menopause will start?
Moreover, these scientists defined that smoking significantly reduced the time to menopause, so still, if we have quite low AMH, we have time until we will be in total menopause because there will be a period of the perimenopausal stage.
This is a clinical syndrome defined by loss of ovarian activity before the age of 40. It’s characterized by menstrual disturbance which is amenorrhoea or oligomenorrhea with raised gonadotropins and low estradiol.
The possible mechanisms of POI can be three, when and in which stage can we decrease the number of follicles?
For some of these issues, we can also have external factors playing the role such as radiation, chemotherapy, surgeries, and more.
If we are talking about premature ovarian failure, we have a non-functioning ovary. There is an ovary with most tissue fibrotic and we cannot see antral follicles there. There are a lot of definitions about how we can call this, the reasons why there is premature ovarian insufficiency, and how to manage this woman with this status.
Talking about aetiology, there’s still some percentage of those being idiopathic, so we cannot find the reason, but for many, there is a genetic factor, such as:
The symptoms of premature ovarian failure would be:
If we would like to test those patients, we would need to do the karyotyping for diagnosis of turner syndrome, test for Y-chromosomal material, fragile-X testing, autosomal genetic testing, and antibodies such as thyroid antibodies, and depending on what conditions will be found, we need to send that patient also to the consultation of the endocrinologist, cardiologist, geneticists, or other specialists.
We also need to consider the standards that if there is a fertility treatment plan we need to understand the needs, what should be next? If we need to decrease the antibody activities because we need to have a successful implantation, we need to work on this together with endocrinologists, but if we do not decrease the antibody activity, we will not be successful in terms of the implantation.
It’s not only one cause of the issue because if we are talking about menopause, this is very important to understand, that menopause doesn’t mean that we cannot be pregnant. Menopause just means that we cannot produce our own follicles and our own oocytes, but still, there are options with the help of IVF specialists to get pregnant. So, even if you are in your premature ovarian failure, you are in early menopause, or you are in your natural age menopause, but you still have plans to be pregnant, it’s still possible until there is not the upper level of the legal limit.
This is another issue. Those limits, in different countries, IVF is regulated differently. For example, in Ukraine, the country where I’m practising, there is no upper limit by law, we only control this on the ethical committee in our facility and also considering the somatic status and the risk for the patients, but we will work if there is a possibility to perform successful IVF treatment.
If you know that in your family there is somebody who is a carrier of X-linked disorders, you need to be tested as well. All relatives of women with the fragile-X premutation should be offered genetic counseling and testing, and control the status of everyone in the family.
It’s also important to understand that we shouldn’t remember only issues related to fertility, but if you are in the period of your early menopause or syndrome being premenopausal syndrome, you need to take care of your bones, your cardiovascular risks, and your fertility.
There is a very efficient method that needs to be used is the Menopausal Hormone Therapy for the management of POI. For patients in their premenopausal periods, their treatment could be either estrogen or micronized progesterone, or a combination of estrogen and progesterone, including or not including testosterone, but this is very individual and only after checking patients individually we can decide what is recommended for this specific patient because if we are talking about a possible implantation we need to keep cycling and we can only use the hormones with the medic external medications.
If we are talking about the possibilities of getting pregnant, you can see the following graph which says that, independently the success rates of fertility treatment decrease with age for women after they’re 35 years old, we see the graph getting down after 44, closer to 46. We have another graph of stable success rates of over 50% for the same group, for all groups of patients who are using oocyte donation treatment, and this is true in good facilities like ours as well. You can even get higher success rates with oocyte donation treatment.
Patients who are dealing with poor oocyte quality and experienced several IVF failed attempts due to impaired embryo development, or who are not producing their own oocytes and have to be treated with the conventional egg donation programs to be able to have a child, but the facility where you are going to perform your IVF treatment or oocyte donation treatment must have advanced procedures to check the quality of the oocytes also for oocyte donors because this is very important and we need to remember that every woman, even if this is a young healthy woman, she can be a carrier of different disorders and different mutations and some of her oocytes will be aneuploid.
Furthermore, due to the status of COVID, there is a practice change that patient should not travel for all kinds of IVF treatment, even with oocyte donation, from their home country if oocyte donation is legal there. We may cooperate with your clinical facility, and it is possible to bring oocytes into your facility, into your home country, and you can find out how this can be done.
If we are talking about oocyte quality, it’s very important to say if you are still producing your oocyte even if this amount is really small, we need to find out what would be the quality by analyzing the egg cytoplasm, Perivitelline Space, polar body, and morphology of your oocyte.
It’s important to say that mitochondria are a battery of a cell and age-related changes in oocyte mitochondria mean that if we have decreased mitochondrial DNA levels it causes morphological changes and increases mitochondrial DNA mutations. This all plays the role that finally we have lower IVF success rates, we have lower fertilization, and we have higher aneuploidy rates. It’s all because of age and because of mitochondrial dysfunction, even if the nuclei and the DNA material, the nuclear DNA, are fine.
That’s why oocyte donation also has alternatives right now.
In this case, DNA which is in mitochondrial DNA, these are 2% of the DNA and 98% of the DNA comes from the nuclei.
Patients aged less than 35 is 30 and 40%, meaning if we are working with oocyte donors, we need to understand that in the cohort of healthy, well-detected, morphologically well-selected oocytes, we will find about 30% of the oocyte, which will lead us into the abnormal embryos because this is nature. We cannot avoid this if we aren’t testing this.
That’s why the oocyte received needs to be checked for genetic status. Now we’re offering oocyte NGS testing and PGT-A testing of the embryos. In Ukraine, this can be done just by request of the patient or according to the medical indications and the advanced maternal age would be or could be a medical indication as well.
Moreover, the unique feature of the female gamete is that the polar body can provide beneficial information about the genetic background of the oocyte without destroying this. Thus, we can get just the polar body biopsy from the oocyte, and we can know about the chromosomal and genetic abnormalities which can be inherited by the offspring.
In addition, this is a procedure which has no risks. The only thing is that we need to vitrify them, one oocyte per straw because after sending the polar body to the laboratory for testing, we need to identify every oocyte.
The advantages of polar body NGS testing from the patient’s perspective are very clear.
As we are willing to take the patient to a successful pregnancy from the initial attempt in our clinic, we are checking all this, we are using all these advanced techniques as well as remembering factors of implantation. These factors are not only to create a euploid embryo, but we already understand that by doing a euploid check for oocytes and euploid check for embryos, we can access the healthy embryo, but also the implantation potential of the endometrium.
That’s why we need to have hormonal replacement therapy for those patients who are in their menopausal period, premenopausal period, premature ovarian failure, etc. Their uterus should be a point of control of the IVF specialist. We need to check that we don’t have a thin endometrium. If we have a thin endometrium, we need to treat it with either growth factor or PRP treatment. We need to do a hysteroscopy before the procedure, if we have any questions, if we aren’t sure about the conditions of the endometrium and the cavity, we are checking individual windows of implantation for many patients with previous, repetitive, negative outcomes because you can see on the following picture, pinopodes.
This is a specific structure in the endometrium which grows at the specific time when the embryo should be implanted, so we call this window of implantation.
Other factors are thyroid function and immune system response. Therefore, by controlling all these factors and checking them, we can make sure that we evaluated everything, and we did our best to make sure that this patient is well prepared and well-treated before the embryo transfer, and having these just two options: healthy euploid embryo and well prepared, responding endometrium, we will be successful.
Another option for oocyte donation is quite often used by our patients. This is the so-called combined oocyte donation.
For all patients who still may produce their own oocytes, we’re offering cycle of their stimulation, sometimes this is after the preparation of PRP treatment, which we call procedure ovarian rejuvenation.
Patient response, one or two oocytes are cultivated in a different dish, but additionally, we have another dish with the prepared donor oocyte previously selected by the patient and performed ICSI and cultivate them in two different dishes. By using this method, we aren’t losing the embryo transfer potential because,e for many patients who are trying their last chance, using their own oocytes, we quite often don’t have a blastocyst for transfer due to the fact of the mitochondrial activity, euploid activity, etc. However, at least we have this backup from the donor material, and we can successfully transfer, but we have this emotional stability that we tried our best, we did what we could, we received oocytes, we fertilized, we cultivated, we selected, we checked morphology, but unfortunately, this is the way we should use to be successful.
It’s better to predict and better to start your treatment earlier because then you will be able to produce your own oocytes and we will have more options for the successful treatment.
The average age of our patients being treated in our facility is 42 years old, and I should say that every year, the average age of our patients is increasing. By increasing the age of the patient, the probability of having patients with the symptoms of premature menopause or early menopause is also increasing, and this is all over the globe.
There is a publication that every 10 years, every decade, the age of the first deliveries of the baby is increasing by two years all over the globe on average, meaning that if we would calculate for the future, so in 2100, the first delivery would be in 51 years old. We, as IVF specialists, need to be ready to offer options for those patients, of course, the best options are to freeze the eggs, like to freeze your fertility, your natural fertility, or freeze ovarian tissue. Still, there was a discussion, a huge discussion, before COVID probably 2 years ago, that if we take a piece of the ovary what we do for our patients with the oncology, and we will freeze the ovarian tissue, and then we will transplant the piece of the ovarian tissue back into the ovary, this tissue will start to produce hormones and we will delay menopause. This option was offered to the patients to delay menopause, but of course, by ethical committees, it was not accepted, just to make surgery, to delay something physiological, with no medical indications. This is still something that we are already talking about, so it’s very common, and it’s more and more in our patient population all over the globe.
This is a time to take care of yourself. There are guidelines for fertility preservation. We should recommend fertility preservation for patients in their age before 38 years old just because of the statistical data that before 38 potential aneuploidy rates would be lower than if you are older.
If we freeze oocytes at an older age, the patient can spend money, we can get a low amount of oocytes, lower quality of the oocytes, and we will end with no results, so this is again an ethical, financial, etc., question. However, from our practical experience, we also know, and we were talking about these PCOS patients, so I know there is a correlation that if a patient was a PCOS patient, she can still respond with more than five oocytes or even closer to 10 in her over 40 years old. It all depends on the individual response of the patient. Many of them would be aneuploid, and probably I would recommend testing them even if there is no male partner, there is a potential to freeze the oxide, and there is a potential to use donor sperm, but it’s a very individual decision.
I would recommend that if you already have signs of early menopause, you check your AMH, you need to visit your fertility specialist, you need to check the number of antral follicles, you need to consider fertility preservation like any doctor can say you know because still there is a possibility for you to getting treatment you just need to understand the risks associated with this or doing a treatment with sperm donation and then moving ahead from there. Everything is possible, but also you need to visit your endocrinologist and cardiologist to check your status regarding symptoms of early menopause and your somatic status.
So, it’s not premenopausal, it’s probably menopause already, but again, it would be great to check AMH, to do the ultrasound evaluation, still, you will be able to carry the pregnancy using oocyte donation if you decide to do this. Some women consider even embryo donation, but you still can be pregnant, you can carry the pregnancy, and many patients share their emotional status that they feel that this is their baby, and there are a lot of publications regarding RNA, which we exchange even if this is oocyte donation, so still there is some genetic from your part and during the baby growing period, you will be with the baby, so still this is a good time to think about and to plan about and don’t delay this.
Unfortunately, yes. Sometimes, it’s happening, but still, you are young, and you can get pregnant with other alternative methods, and you should not delay planning this, independently of what you would select.
Some women, like 1%, I even think it’s more than one, and maybe this is ecological factors playing the role, we don’t know, but we started to see more patients with premature ovarian failure, unfortunately.
Frankly speaking, I’m lecturing quite a lot and I already included in my slides that fresh oocyte donation was a gold standard 5 years ago and now vitrified oocyte donation is a gold standard; however, there are some limits, and we need to consider a few factors.
The most important factor is the facility, that did the freezing of the eggs, and also the facility that going to do the thawing. These two technologies are very simple, they are very commonly used; however, there are different laboratory conditions and different embryologists and in our oocyte banking data, we have real data coming from different clinics, even recommend following the protocol and even if we know the team and the embryologist who did the petrification by doing thawing, by different embryologists in different conditions of the air, quality, humidity, temperature, protocol used, the volume of the media used, they are getting different results.
If you are not sure about the facility and the conditions for the oocyte petrification and thawing, it’s better to use fresh, probably. However, fresh also has some advantages and disadvantages. The advantage is that it’s more commonly used in some locations, in some laboratories, but the disadvantage is that the donor cannot respond with the expected number and quality of her oocytes, even if her previous cycle was fine like something happened, she missed the medication, she mixed up something, she forgot to do the injection, you were synchronized, but you needed more time to prepare your endometrium. Donor follicles were already big enough to do the oocyte pickup, but because you are synchronized the doctor decided to postpone the pickup for sizes of follicles of 24, and 23 NG/mL, and oocyte quality will not be optimal in this situation.
This asynchronization and the risks that the donor will do something wrong are also, I would say they’re also huge, so I would recommend just considering the facilities which have the best results for oocyte vitrification and thawing, mainly these are facilities that could do a lot of those cases, and their results are wonderful, the working result is over 95% of the oocyte being survived, and there is no difference in fertilization, blastulation rates, and clinical pregnancy rates.
Yes, we do everything that I mentioned. We do pronuclear transfer, spindle transfer, and combined oocyte donation program, like everything that was mentioned we do it successfully in our centre.
Yes, we do. For all patients who are coming to visit us, mainly those who are coming to our facility are looking for pregnancy, and if we are talking about pregnancy, even with their diagnosis of premature ovarian insufficiency, then we are considering, if we still can consider, stimulation and if you are considering stimulation we are using recombinant FSH to grow the follicles if they are existing or if we are moving to the oocyte donation we are moving to the treatment.
Cycloprogynova is usually used for the preparation of the endometrium of those patients, but if this patient is not, for example, for some reason, she is not ready to be pregnant right now, we recommend hormonal replacement therapies because it is very important for also the health of the bones, all these conditions even sexual feeling intercourse, vaginal dryness, etc., so these women need to have hormonal replacement therapy. It can be different, but it needs to be selected individually, case by case.
We did a lot of research, and we are sharing our data regarding the PRP treatment. We divided the group of our patients into the groups of potentially being good responders for PRP, and those for whom we should try, but we should not expect a wow effect, let’s say.
From what we understood how PRP works that once we are injecting PRP into the ovaries, we are helping those follicles which are existing in the cortex because they are still there. So, if we are cycling, even if we do not cycle regularly, we still have about 100 up to 500 follicles in our ovaries, but they are in different stages of development and follicles need to be at a stage of being sensitive for gonadotropins.
By injecting PRPs we are helping follicles which are in their preliminary stage, being insensitive to gonadotropins to grow faster, a bit faster, to be sensitive, and after injection of the PRP, we see mainly after two months or in a period after the injection up to two months, that we started to see small antral follicles in the ovaries by doing ultrasound evaluation. For all patients, we saw decreased FSH and a bit of increased AMH because it’s quite sensitive, and for some, it was increasing, for some not, but still, we saw antral follicles, and as soon as we saw antral follicles, we started our stimulations. So, it works well, but it works best for this category of women who still have some AMH, for us, this cutoff was 0.3, so if the patient had 0.3 and more, if she was, like, our oldest patient was 47, but she was trying everything to get pregnant. Unfortunately, PRP was not working for her as well, and we moved just to the regular oocyte donation, but for many patients, and mainly for their age, less than 42 and AMH over 0.3, it works well.
Evidence, is considered to be a clinical trial or experimental treatment, and we sign the consent with each of our patients for experimental treatment, but there is no risk. We need to understand that PRP treatment is used commonly in different areas of medicine, in traumatology, in cosmetology, and everywhere, and it works, as well it works for gynaecology and fertility.
Yes, for your somatic status, you should request to be referred, and there is a special test which needs to be done for your bones and your cardiovascular system, but in terms of your gynaecologist you can also discuss an issue and if you will have a need. I don’t know which country you are located in, but if you don’t have an opportunity to be treated with any kind of advanced techniques we are offering or even oocyte donation because it’s very limited in some countries or there are no options for oocyte donation, you can always travel.
Right now, the travel restrictions there are almost any, you just need to be either vaccinated or do the PCR testing, and we will coordinate and plan all your visits and the activities in our country in case this would be needed, but of course a lot you need to do at your home country if you are talking about all other options not directly fertility.
Yes, hormonal replacement therapy should be advised, but after performing the hormonal profile and ultrasound evaluation, so probably your gynaecologist will advise you, or you need to ask her or him to advise your hormonal replacement therapy.
Side effects can be connected to the thrombotic status and your vessels, but again, this will be checked before the hormonal replacement therapy is advised these risks are very minor, but to be more specific, you can contact us if you need to have a second opinion, but better to go to your gynaecologist, ask all those questions, and then if you need to check anything else, or you need to double-check or, as I said, the second opinion you can write, but we would need to be more specific in terms of what is your today estradiol level, what is your progesterone level, what is your FSH, what is your ultrasound evaluation, etc., before we will be happy to advise anything.
There was probably, 3 or 5 years or maybe 6 years ago, there was a boom regarding testosterone and all other supplements which consist of testosterone. Many clinics are offering this supplement to their patients, including in the protocol or advising them to take it before the treatment, us included. However, according to the Cochrane database and scientific publications, this still was more commercial than it was confirmed by real science and evidence.
We understand that for some women some testosterone would work well, but it was not as a category A that it should be included in all IVF treatment regimens. Personally I, like some of my patients, accept different supplements, we include also vitamin D, Coenzyme Q10, and some others. We created a list of what we would advise, but again we need to know more about that patient, we need to receive some of her results, we are asking for some specific, and we need to have the medical history of that patient. So, based on this, we do recommend some supplements, or we don’t, but we need to understand that there is no evidence-based confirmation for this specific medication as well, my personal opinion is there is no harm if you are not getting more than it is advisable like maximum is three times per day as maximum 25 milligrams, so total 75 milligrams.
