Seminar Presentation Molina Dayal MD 9-13

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The basics of In Vitro Fertilization. Presented by Molina Dayal, MD of the Sher Institute for Reproductive Medicine

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Seminar Presentation Molina Dayal MD 9-13

  1. 1. In Vitro Fertilization: the basics…. Molina B. Dayal, MD Medical Director Sher Institute for Reproductive Medicine, St. Louis
  2. 2. All Couples 1 in 8 Couples Age 30-34 1 in 6 Couples Age 35-39 1 in 4 Couples Age 40-44 1 in 2 Couples
  3. 3.  Inability to conceive after one year’s worth of regular unprotected intercourse: Can this be applied to everyone? Age. Ovulatory status. Known tubal or male issues.
  4. 4. Infertility --- Basic Statistics  20-25% couples conceive/month in 1st year  85% of couples will have conceived in one year  Those 15% who did not conceive will have a monthly chance of conception of 2-3%/month  2-3%/month is achieved after just 6 months if the woman is 35 years old or older
  5. 5. Causes of infertility • Ovulatory Factor • Egg Factor • Tubal Factor • Uterine Factor Sperm Quality 50% 10% 40% Unknown Immunologic
  6. 6.  Assessment of ovulation  Ovarian reserve screening  Assessment of pelvic anatomy (Hysterosalpingogram (HSG))  Semen Analysis  Immunologic
  7. 7. What should be done with the information?
  8. 8. Cause of Infertility • Ovulatory Factor • Decreased Ovarian Reserve • Tubal Blockage Or Abnormality Treatment • Ovulation Induction • Clomid, etc • IVF • ?Egg donor • IVF • Surgery very unlikely to be successful
  9. 9. Cause of Infertility • Mild Male Factor • Moderate to Severe Male Factor • Uterine Factor Treatment • Fertility Meds + IUI • IVF (ICSI) • Surgery
  10. 10. Cause of Infertility • Unexplained • Immunologic Treatment •Fertility Meds + IUI •IVF
  11. 11. A few words about Intrauterine Insemination (IUI)
  12. 12. Overall IUI Success Rates 15% for women under the age of 30, 12% for women ages 30 to 35, 7% to 8% for women ages 35 to 39 < 2% for women over the age of 40.
  13. 13. Clomid with IUI  Success rate dependent on age of female and sperm quality of male  <35 years old ---- 10%  35-40 years old ---- 5%  >40 years old ---- <2%  Unfortunately, Clomid can have a negative impact on uterine lining (therefore approx ½ chance of success compared to overall chance with IUI)
  14. 14. Unexplained Infertility: Intrauterine Insemination Study Likelihood of Pregnancy per Month IUI vs. No treatment 4% vs. 3% Clomid alone vs. No treatment 3% vs. 3% Clomid + IUI vs. No treatment 8% vs. 3% FSH inj + IUI vs No treatment 12% vs. 3%
  15. 15. Intrauterine Insemination (IUI)
  16. 16. IVF is oftentimes thought of as a ‘last resort’ but it shouldn’t be….
  17. 17. IVF should be considered as the FIRST line treatment if…. Male factor (abnormal semen analysis) Tubal factor (blocked or diseased fallopian tubes) Advanced maternal age Pre-implantation genetic diagnosis/cGH testing
  18. 18. IVF should be considered as the FIRST line treatment if…. Pre-implantation genetic diagnosis (single gene disorders/disease carrier states) Protracted infertility Immunologic Implantation Dysfunction Need for gestational carrier Fertility Preservation
  19. 19. What is IVF?  It is the fertilization of eggs with sperm/generation of embryos outside the body  Multi-step process  Medications (“protocols”) for patients are individualized to optimize outcome
  20. 20. IVF: Manipulation of Normal Physiology FSH E2
  21. 21. Deprogramming  Birth control pill  Lupron  Ganirelix  De-programs hypothalamic/pituitary axis.  Prevents ovulatory/LH surge.
  22. 22. Stimulation of Follicles Using FSH (follicle stimulating hormone) to stimulate follicles
  23. 23. Ultrasound Guided Oocyte Retrieval
  24. 24. The Fertilization Procedure Intracytoplasmic Sperm Injection (ICSI)
  25. 25. Fertilization Check
  26. 26. Embryos at the Blastocyst Stage
  27. 27. Embryo transfer
  28. 28. Solving the Embryo Selection Dilemma Blastocyst transfer cGH testing
  29. 29. Embryo Selection Dilemma Issues related to the transfer of early cleavage stage (day 3) embryos - Which is normal? Morphology scoring: Cleavage rate. Blastomere symmetry. Degree of fragmentation.
  30. 30. Embryo Aneuploidy ≥40/normal appearance 67% ≥40/abnormal appearance 70% Munne et al, Fertil Steril. 1995. Chromosomal abnormality rates in embryos increase with maternal age even if the embryos appear normal Age/Embryo Type (on day 3): Rate of Chromosome Abnormalities:
  31. 31. Why a blastocyst transfer?  Depending on maternal age, the majority of blastocysts are chromosomally normal.  More efficient (less risk of high order multiple pregnancies).  More physiologic.
  32. 32. Why cGH?  While the majority of blastocysts are normal in younger women, this does not hold entirely true in older women.  Able to screen embryos, with high accuracy, for chromosomal abnormalities (Down Syndrome, etc) before an embryo transfer is performed.
  33. 33. Testing for Aneuploidy/Single Gene Disorders:The Embryo Biopsy
  34. 34. Following Embryo Biopsy Report generated indicating findings from genetic analysis. Patient and physician decide how many and which embryos to transfer. Normal embryos are transferred/stored for later use while abnormal ones are disposed.
  35. 35. Additional Advantages of IVF Assessment of ovarian reserve. Assessment of fertilization. Control number of embryos placed in uterus. Ability to freeze/store embryos for later use.
  36. 36. Take Away Points  Seek evaluation from a fertility specialist after one year of infertility (or sooner if the woman >35 years old, has irregular cycles or there is a known male factor)  Consider fertility medications + IUI in cases of unexplained infertility, limiting treatment to no more than 3 attempts  Consider IVF as first line treatment when ovarian reserve is of concern, tubal disease/blockage and male factor are present, multiple IUI’s have failed, if an immunologic implantation issue is discovered, or you are interested in cGH testing.
  37. 37. Thank you!

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