Techniques Of Art

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  • The first attempt at IVF in humasn was attempted in the 1970s in England by PS and BE.They used HMG/hcG stimulation and retrieved eggs laparoscopically for GIFT.
  • By the 1980s, a PR of 15% per natural IVF cycle was attained.
  • This figure by the CDC demonstrates the increasing # of IVF centers nationwide. As of 2006, there were 463 clinics with a total of 136k cycles reported. Most are concentrated in the Eastern US.
  • About 72%of all ART cycles done are fresh-nondonor cycles……………
  • Some of the common indication for IVF are
  • During an ART cycle, pts routinely undergo
  • Initial success with IVF was accomplished using natural cycles: However, compared to current standards, this approach is not very practical due to need for frequent monitoring for a spont LH surge….Retrieval timing during the day or night….and low preg rates.
  • Instead IVF cycles are most always done using GT COH.The starting dose should be determined keeping a variety of factors in mind.
  • Patients are closely monitored via interval TVUS and serum E2 levels. Pts usually require 10-12 days of stim with a margin of a few days.
  • We commonly use GnRH agonist,i.eLupron, for many reasons:
  • These are two traditional IVF protocols using GnRH agonists, typically Lupron in the US, for initial down-regulation and prevention of premature ovulation.
  • Use of birth control pills allow more control in timing of procedures especially in patients with irregular cycles.
  • Egg retrieval is carried out around 36 hours after HCG triggering. Oocytes are aspirated under transvaginal ultrasound guidance using either a mechanical suction pump or syringes. The preferred method of anesthesia is deep sedation which we will discuss later in the talk.. After egg retrieval the oocytes are fertilized by mixing with husband or donor sperm in the IVF lab in petri dishes.
  • Some centers, may use AH to facilitate the process. AH, in human embryos, was first reported in 1990.
  • Studies have demonstrated that hatching using the laser has higher pregnancy rates compared to mechanical methods.
  • Nevertheless, reviewing the principal studies investigating the value of AH fails to reveal a benefit in pts with a good prognosis.
  • ICSI, on the other hand is widely used to facilitate fertilization, both in cases of severe male factor and with in cases of failed prior fertilization.
  • Here we see that interestingly over half of all ICSI cases do no involve cases of male factor infertility….illustrating the growing applications for ICSI.
  • And then we are faced with the question of when to transfer?
  • According to the 2006, SART data, in 64% of fresh cycles, embryos were transferred on day 3, with only 27% on day 5.
  • Additionally, growing the embryo out to day 5 is thought to enhance embryo selection which could facilitate a higher IR as well dec the # of embryos that need to be transferred, hence decreasing the multiple preg rate.
  • The drawbacks to day 5 transfer include:Extended embryo culture is much more successful using sequential media, and is less tolerant of suboptimal culture conditions
  • When comparing day 3 to day 5 transfer, you see a 27% twin rate amongst the day 3 transfer cycles and a 33% twinning rate in the day 5 transfer cycles.Higher rate of twinning, particularly MZ twinning with Day 5 transfer.
  • However, the preg rates amongst the blast transfer cycles are higher across all age distributions.
  • Then comes the question of embryo transfer technique.
  • , a Cochrane Review, released in 2007 similarly demonstrated improved clinical pregnancy rates as well as
  • Live birth rates with US guided embryo transfer compared to blind transfer.
  • A subsequent rct by Kosmas, published in HR in 2007 failed to confirm a benefit, in either ease of transfer, nor in cpr.
  • Dr. Doody’s study in 1997 demonstrated that propofol levels do not appear to be affected bythe length of sedation prior to follicle aspiration. Contamination with blood significantly increases propofol concentration.
  • Next, I’ll discuss various outcome predictors for ART cycles.The ave age of women undergoing ART is 36. As you can see, here, the majority of cycles are performed on women <35, however, Of note, is the growing % of patients in the advanced age category who are seeking ART services.he average age of women using ART services in 2006 was 36. The largest group of women using ART services were women younger than 35, representing 39% of all ART cycles carried out in 2006. Of note, is the growing % of patients in the advanced age category who are seeking ART services.
  • In contrast, to the declining PR as a fxn of advancing age, you see that the PR using donor eggs remains stable and independent of age and hence a viable option in this population.
  • of 1500 egg retrievals for IVF-ET, Govaerts (1998) in Eur JObstetGynecolReprodBiol
  • Techniques Of Art

    1. 1. ART<br />Satin Patel, MD<br />December 2, 2009<br />
    2. 2. Objectives<br />History of Assisted Reproductive Technologies<br />Understand ovarian stimulation and methods of monitoring follicular development<br />Understand oocyte retrieval methods<br />Compare cleavage stage vsblastocyst transfer<br />Guidelines for # of embryos transferred<br />Review techniques of embryo transfer<br />Review complications of ART and their prevention and treatment<br />
    3. 3. History of ART<br />Early 1970’s<br />First attempt at GIFT by Patrick Steptoe & Roberts Edwards, United Kingdom<br />Used HMG/hCG simulation and laparoscopy for egg retrieval.<br />Transferred 1 to 2 eggs and millions of sperm into ampulla<br />
    4. 4. History of ART<br />1978 2003<br />World&apos;s first test-tube baby Louise Brown has a child of her own <br />Louise Brown, the first test-tube baby in the world, has given birth to a child of her own. The boy ­ named Cameron ­ was conceived naturally and without IVF. <br />He was born weighing 5lb 6oz at St Michael&apos;s Hospital in Bristol just before Christmas and Louise describes him as &quot;tiny but perfect&quot; in an interview with The Mail on Sunday. <br />
    5. 5. History of ART<br />1980s<br />15% per cycle pregnancy rate with natural cycle IVF<br />1984<br />Two pregnancies following transfer of frozen-thawed embryos (Zeilmaker)<br />1985<br />Transvaginal US-guided oocyte retrieval (Wikland)<br />
    6. 6. History of ART<br />1990<br />PGD introduced, initially to screen for X-linked disorders (Handyside)<br />1992<br />Advent of ICSI (Belgium)<br />
    7. 7. Abdulkareem Sultan Al-Olama<br />7<br />Definition of Infertility & ART<br />Infertility is defined classically as the inability to conceive after 1 year of unprotected intercourse. This definition is based on the cumulative probability of pregnancy:<br />
    8. 8. Abdulkareem Sultan Al-Olama<br />8<br />Month<br />Monthly Probability<br />Cumulative Probability<br />1<br />0.2<br />0.20<br />2<br />0.2<br />0.36<br />3<br />0.2<br />0.49<br />4<br />0.2<br />0.59<br />5<br />0.2<br />0.67<br />6<br />0.2<br />0.74<br />7<br />0.2<br />0.79<br />8<br />0.2<br />0.83<br />9<br />0.2<br />0.86<br />10<br />0.2<br />0.89<br />11<br />0.2<br />0.91<br />12<br />0.2<br />0.93<br />Definition of Infertility & ART Cont’d<br />
    9. 9. Abdulkareem Sultan Al-Olama<br />9<br />Definition of Infertility & ART Cont’d<br /> ART refers to all techniques involving direct retrieval of oocytes from the ovary<br />ART procedures include IVF, GIFT, ZIFT, and ICSI.<br />The simplest ART procedure, IVF has been around for over 20 years and is perhaps the most commonly recognized ART of all procedures. <br />
    10. 10. AGING AND INFERTILITY<br />
    11. 11. Abdulkareem Sultan Al-Olama<br />11<br />Common causes of infertility Cont’d<br />Female factors<br />Cervical factor<br />Ovulatory factor (PCOs)<br />Uterine factor (endometriosis)<br />Pelvic factor<br />
    12. 12. 12<br />IVF<br />Hyper ovulation<br />Egg Retrieval<br />Artificial Insemination <br />Embryo Transfer<br />                                                                             <br />
    13. 13. ART<br />
    14. 14. Types of ART (2006)<br />
    15. 15. IVF - Indications<br />Tubal Factor<br />Severe male factor<br />Diminished ovarian reserve<br />Endometriosis<br />Advancing age<br />Third party reproduction<br />Unexplained infertility<br />
    16. 16. IVF – Current Methods<br />Precycle Work-up<br />Ovarian Stimulation<br />Egg Retrieval<br />Embryo Transfer<br />PGD<br />Laboratory Handling<br />
    17. 17. Precycle Workup<br />Assess Ovarian Reserve<br />Day 3 FSH; AFC; CCT; AMH<br />Assess Uterine Cavity<br />Sonohysterogram; HSG; Office Hysteroscopy<br />Semen Analysis<br />Male and Female ID labs<br />Genetic screening<br />
    18. 18. Ovarian Stimulation<br />Natural cycle IVF<br />Very frequent monitoring for spontaneous surge<br />Retrieval can occur anytime, day or night<br />Low pregnancy rates (~15%)<br />Low efficiency and practicality<br />
    19. 19. Ovarian Stimulation<br />Gonadotropin COH<br />Starting dose<br />Age<br />Ovarian reserve testing<br />Diagnosis <br />BMI<br />Response in prior cycles<br />
    20. 20. IVF –Monitoring<br /><ul><li> Dose adjusted based on US and E2 monitoring
    21. 21. Usually requires 10-12 days of stimulation</li></li></ul><li>Ovarian Stimulation<br />GnRH Agonists (Lupron)<br />Increase pregnancy rates, decrease cycle cancellations due to poor response or premature LH surges and allow batching<br />GnRH Antagonists (Cetrotide, Antagon, Ganirelex)<br />Lack the “flare effect” of agonists<br />May be used to suppress the ovary prior to cycle start<br />May used to prevent premature LH surge (~14mm)<br />
    22. 22. Ovarian Stimulation<br />OCP Pretreatment<br />Prevents cyst formation by GnRH agonists, decreases cycle cancellation, increases oocyte number and fertilization rates<br />hCG<br />Purified Human (5,000 – 10,000 U) or Recombinant hCG (250 mcg) is given when 3 follicles are &gt; 18 mm in average diameter<br />Resumption of meiosis and oocyte maturation and GC luteinization<br />
    23. 23. Ovarian Stimulation - Protocols<br />
    24. 24.
    25. 25. Transvaginal Egg Retrieval<br />
    26. 26. Assisted Hatching<br />
    27. 27. Assisted Hatching<br />Various protocols have been described<br />Partial zona dissection<br />Acid Tyrode’s assisted hatching<br />Laser-assisted hatching<br />Zonapellucida thinning<br />
    28. 28. Laser vs Mechanical AH<br />
    29. 29. Assisted Hatching<br />
    30. 30. Assisted Hatching<br />AH does not appear to improve the pregnancy rate or implantation rate in 1st IVF attempts.<br />It does appear to be beneficial in patients with prior implantation failures.<br />It is unclear whether AH helps patients in FET cycles, of advanced age or with thick ZPs.<br />There is insufficient evidence to routinely recommend AH in patients undergoing ART.<br />
    31. 31. ICSI<br />
    32. 32. ICSI<br />
    33. 33. ICSI<br />
    34. 34. Indications for ICSI<br />Moderate to severe male factor<br />Epididymal or testicular sperm<br />History of failed fertilization with IVF<br />Antisperm antibodies<br />Low egg number<br />
    35. 35. ICSI Concerns<br />Damage to the oocyte (meiotic spindle)<br />Override natural safeguards that serve to prevent fertilization by abnormal sperm<br />Transmission of paternal genetic abnormalities<br />Sex chromosomal abnormalities<br />Y chromosome microdeletions<br />Karyotyping and Y chromosome deletion analysis should be offered to all men with severe male factor infertility who are undergoing ICSI.<br />
    36. 36. ICSI Use<br />
    37. 37. Embryos (Day 1 and Day 3)<br />Day 3: 8 cell embryo<br />Day 1: male and female pronuclei<br />
    38. 38. Embryo Development<br />2-cell<br />4-cell<br />8-cells<br />
    39. 39. Blastocyst Transfer<br />hatched blastocyst<br />
    40. 40. Blastocyst (Day 5)<br />ICM – Inner cell Mass<br />TE - trophectoderm<br />
    41. 41. Embryo Transfer<br /><ul><li>Abdominal USN guided</li></li></ul><li>Day 3 or Day 5 Transfer<br />DAY 3<br />DAY 5<br />
    42. 42. Day of Embryo Transfer<br />
    43. 43. Blastocyst Transfer (Day5)<br />Advantages:<br />Synchronizing embryo replacement with the endometrium<br />
    44. 44. Blastocyst Transfer<br />hatched blastocyst<br />
    45. 45. Blastocyst Transfer (Day 5)<br />Advantages:<br />Synchronizing embryo replacement with the endometrium<br />Enhance embryo selection<br /><ul><li>Higher implantation rate
    46. 46. Decrease the # of embryos transferred
    47. 47. Decrease multiple gestations</li></ul>Longer time in culture provides opportunity for Preimplantation Genetic Diagnosis (PGD)<br />
    48. 48. Blastocyst Transfer<br />Disadvantages<br />More demanding of embryology lab personnel and equipment<br />Requires modified cryopreservation and thawing protocols<br />More cycles are cancelled due to lack of embryos to transfer (Less embryos to freeze)<br />Increase rate of twinning<br />
    49. 49.
    50. 50. Day of Transfer Success Rates<br />
    51. 51. Techniques of Embryo Transfer<br />
    52. 52. USN-guided Embryo Transfer<br />Randomized-controlled trial (2002) – Vizcaya, Spain<br /><ul><li> abdominal US guidance (n = 255 women)
    53. 53. clinical touch embryo transfer (n = 260)</li></ul>Clinical pregnancy rates (87% Day 3 transfers):<br /><ul><li> 26.3% (67/255) in the US-guided transfer group
    54. 54. 18.1% (47/260) in the clinical touch transfer group (P < 0.05)</li></ul>Implantation rate – 11.1% vs. 7.5%<br />“Easy” transfers – 97% vs. 81%<br />
    55. 55. Cochrane 2007<br />
    56. 56. Cochrane 2007<br />
    57. 57. Human Reproduction 2007<br />
    58. 58. Anesthesia and IVF<br />Adequate pain control is important for patient safety and comfort<br />Wide variation in anesthetic technique amongst centers internationally.<br />In the US, 95% of centers use conscious sedation<br />
    59. 59. Anesthesia and IVF<br /><ul><li>Studies have demonstrated a higher pregnancy rate with conscious sedation (28.2%) than under general anesthesia (16.3%)
    60. 60. Important factors to consider when choosing an anesthetic agent</li></ul>Whether the substance enter the follicular fluid<br />The toxicity of the anesthetic agent<br />
    61. 61. Anesthesia and IVF<br />Propofol is widely used during egg retrieval procedures<br />The safety of Propofol has been extensively described in the ART literature<br />Follicular fluid concentrations do not appear to increase with time of retrieval (length of sedation)<br />No difference in fertilization, cleavage and embryo cell number with Propofol<br />
    62. 62. Anesthesia and IVF<br />Midazolam (Versed)<br />Most commonly used benzodiazepine for conscious sedation<br />Minimal amounts are found in follicular fluid<br />No adverse effect on fertilization<br />
    63. 63. Anesthesia and IVF<br />Patients are commonly given Versed 1 mg; Fentanyl 50 µg; Propofol 1.5-2 mg/kg.<br />Spontaneous ventilation via face mask O2<br />
    64. 64. Cryopreservation (Freezing)<br />Embryos<br />Can be frozen at any state from 2PN zygotes to blastocysts<br />Slow freezing vsvitrification<br />Freezing at the blast stage may enhance identification of the best oocytes for subsequent transfer<br />~80-85% of frozen blasts survive thawing and rexpand<br />
    65. 65. Cryopreservation (Freezing)<br />Sperm<br />Cryopreserved husband or donor sperm may be used for ICSI or IVF and couples may freeze husband’s sperm as a back-up in case of difficulty collecting the day of retrieval<br />In cases where epididymal or testicular extraction is performed, donor sperm-back up in recommended<br />Oocytes<br />Currently experimental<br />
    66. 66. Age and ART<br />
    67. 67. Effect of Maternal Age<br />
    68. 68.
    69. 69. ovulated follicles<br />ovulated follicles<br />growing follicles<br />atretic<br /> follicles<br />atretic<br /> follicles<br />follicular<br /> pool<br />atretic<br /> follicles<br />follicular pool<br />FERTILE ADULT<br />PREPUBERTAL<br />MENOPAUSAL<br />Ovarian physiology<br />
    70. 70. Ovarian Physiology<br />A woman goes into puberty with about 400,000 eggs.<br />During the reproductive years, usually only a single egg matures each cycle<br />Oocytes (Millions)<br />at birth<br />puberty<br />20 weeks<br />6-7 weeks<br />menopause<br />
    71. 71. <ul><li> Women over 35 years of age
    72. 72. Previous oophorectomy
    73. 73. History of extensive ovarian surgery
    74. 74. Unexplained infertility
    75. 75. Previous chemotherapy or radiation
    76. 76. Heavy smokers</li></ul>Who is at risk for decreased ovarian reserve?<br /><ul><li>Uterine artery embolization</li></li></ul><li>Ovarian Reserve Testing<br /><ul><li>CCCT (Clomiphene Citrate Challenge Test)
    77. 77. A dynamic test of ovarian reserve
    78. 78. Clomidis given at a dose of 100 mg/day on cycle days 5 – 9 with measurement of FSH and E2 levels on Day 3 and repeat FSH on Day 10</li></li></ul><li>serum<br />FSH<br /> serum <br />FSH<br />100mg CC<br />3<br />5<br />9<br />10<br />cycle day<br />Clomid Challenge Test<br />Abnormal: FSH &gt;10 mIU/ml before or after CC, D3 or D10, <br />or E2 &gt; 70 on D3<br /> FSH 10-12 borderline, increase FSH dose<br /> FSH 12-14 ↓ PR<br /> FSH &gt;= 14 – very few clinical pregnancies<br />
    79. 79. Ovarian Reserve TestingAntral Follicle Count (AFC)<br />Ultrasound during early follicular phase<br />6-10 antral follicles per ovary is normal<br />&lt;6 total predicts poor response – ↑ FSH dose, reduced pregnancy rates<br />AFC may be a better predictor of response than FSH<br />
    80. 80. Abnormal (increased)<br />20-30 antral follicles in a PCOS ovary<br />Antral Follicle Count (AFC)<br />Normal – 6 to 10 antral follicles<br />
    81. 81. AMH<br />Recent studies suggest that AMH is a superior marker for diminished ovarian reserve as compared to d3 FSH and Antral Follicle count.<br />AMH levels correlate well with the total developing follicular cohort as well as response to gonadotropin stimulation.<br />
    82. 82. Pregnancy Loss Rates by Age<br />and Ovarian Reserve<br />Pregnancy Loss Rates (%)<br />Age in Years<br />Scott et al 1999<br />
    83. 83. Pregnancy Loss Rates after + FHM by Maternal Age<br />Effect of maternal age on pregnancy loss rates after early documentation of fetal cardiac activity by TVUS<br />Smith & Buyalos 1996<br />
    84. 84. Complications of IVF<br />Short-term complications<br />Intraperitoneal bleeding<br />Pelvic infections<br />Adnexal torsion<br />Ectopic pregnancy <br />OHSS<br />
    85. 85. Complications of IVF<br />Long-term Complications<br />Multiple pregnancy<br />Perinatal outcome<br />Lower birth weights<br />Genetic abnormalities<br />Congenital malformations<br />Epigenetic changes<br />Ovarian cancer risk ?<br />
    86. 86. Multiple Pregnancies<br />
    87. 87. Complications of IVF-Multiple Pregnancies<br />
    88. 88. Number of Embryos Transferred during ART Cycles (2006)<br />
    89. 89. SART/ASRM Guidelines for the Number of Embryos Transferred (2008)<br />
    90. 90.
    91. 91. PGD<br />
    92. 92. Engineering 124; Spring 2003<br />83<br />Commonly, more than 100 diseases can be detected through testing, including…<br />Hemophilia A<br />Muscular dystrophy<br />Tay-Sachs disease<br />Cystic fibrosis<br />Down Syndrome<br />Removal of one cell for testing<br />PGD is not a new technology, but is due to the application of old techniques to the new knowledge gained from the Human Genome Project. <br />
    93. 93. Engineering 124; Spring 2003<br />84<br />Viable and Desirable?<br />“This information is helping parents choose which embryos they want--and which to reject as unhealthy, or merely undesirable.” (Zitner 2002)<br />
    94. 94. Engineering 124; Spring 2003<br />85<br />Undesirable Embryos<br />Disease Free Embryos<br />Frozen in storage <br />Donated to infertile couples<br />Donated to stem cell research/usage<br />Disease Carrying Embryos<br />Donated to research<br />Discarded<br />
    95. 95. THANK YOU<br />

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