On October 23rd, 2014, we updated our
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1960 - Steptoe and Edwards achieved human pregnancy ,unfortunately turned out to be ectopic.
1978 – birth of LOUISE BROWN
unstimulated natural cycle IVF
Miracle baby-Louise Brown
FIRST IVF BABY
Since the birth of the first IVF baby, Louise Brown, at 11.47pm on July 25, 1978, in Oldham, there have been well over a million "test tube babies" born worldwide
“ We are at the end of the beginning – not the beginning of the end.”
- Patrick Steptoe 1978 .
WHAT ARE WE LOOKING AT ???
Evidence based medicine
Quality control in the labs
Simplifying diagnosis & treatment
Better pregnancy rates
What has the last decade given us ??!!
Sperm Preparation methods
Micromanipulation techniques -ICSI, SUZI
Embryo and sperm preservation
Prenatal diagnosis & treatment
Polar body biopsy
Alternative assisted conception techniques
Direct intraperitoneal insemination- first described by Manhes and Hermabessiere.
Fallopian tube sperm perfusion or intrafallopian insemination.
Peritoneal oocyte sperm transfer (POST).
Alternative assisted conception techniques
TET (tubal embryo transfer)
Surgical embryo transfer or transmyometrial embryo transfer.
MESA / PESA
The first step towards solving
COH was first acheived with clomiphene citrate but this was later superceded with the use of HMGs and urinary FSH preparations.
Introduction of GnRH agonists permitted the down regulation of pituitary gland in order to eliminate any premature LH surge and various protocols were suggested and used successfully.
Odds ratio for clinical pregnancy rates with various stimulation protocols 1.21 Recombinant vs urinary FSH 0.79 GnRH antagonists vs agonist 1.8 GnRH a vs HMG 1.47 Long vs ultrashort 1.27 Long vs short protocol 1.32 Long vs short and ultrashort 1.70 Urinary FSH vs HMG ODDS RATIO STIMULATION PROTOCOL
Urinary to recombinant Gn
Bye-bye urinary gonadotrophins?
Recombinant FSH: A real progress in ovulation induction and IVF?*
pure ( recombinant) product in principle preferable to an impure ( urinary) product
- human ( urinary) products carried a risk of infection by slow-viruses, raising concerns
- human products, since impure, carried a risk of immunogenicity
- human products had repeatedly been demonstrated to be uneven in biological potency.
CO -CULTURE systems
V ero cell line, granulosa cells as well as autologous cryopreserved endometrial cells
Improvement in cleavage rate, embryo morphology and blastocyst formation rate reported.
RCTs have failed to confirm an increase in pregnancy rates.
Veiga et al ,Human Rep ,14
DAY 3 TRANSFER AND BLASTOCYST CULTURE
Prolonged culture of embryos are suggested to select the embryos with best potential for survival.
RCTs did not find significant changes in pregnancy or implantation rates when embryos were replaced on day 2 or 3 after oocyte retreival.
Assisted hatching Laser Zona Drilling
Advanced maternal age
Repeated IVF failures
Elevated basal FSH
frozen thawed embryo
Excessive fragmentation >20 %
RCTs have not so far shown any clinical advantage in using co-culture systems, group culture ,in vitro maturation or assisted hatching.
Embryo selection methods and blastocyst culture do not improve pregnancy rates but diminish the incidence of multiple pregnancies.
Hassan Salam ,Recent advances in Obs and Gyn,22
IN VITRO MATURATION
IVM of human oocytes was suggested in order to achieve fertilization of immature oocytes retreived
- during stimulated cycles
- oocytes from PCOS patients to avoid OHSS
-after freezing -thawing of immature oocytes.
?No advantage in terms of clinical pregnancy and implantation rates.
Towards single embryo transfer
Multiple gestations is the most common side effect of an ART programme.
Increasing inclination towards minimum to single embryo transfer.
Daunting challenge encountered –identifying best embryo without compromising the pregnancy rate.
Embryo selection based on morphology.
Oocyte morphology as a predictor of embryo morphology.
Polar body morphology as an indicator of embryo quality.
Pronuclear stage scoring.
Pre implantation genetic diagnosis
Useful in recurrent spontaneous abortions and repeated IVF failures
PGD involves embryo biopsy and genetic analysis which can be performed on
- oocyte /zygote – polar body biopsy
- blastomere from cleavage stage embryo
- trophectoderm biopsy from blastocysts.
PGD can be applied for monogenic disorders or chromosomal abnormalities using diagnostic techniques like
CGH – comparative genomic hybridization is a molecular cytogenetic technique tried for PGD which gives an overview of the whole genome.
Various techniques have been suggested in order to optimize this apparently simple step.
The value of using soft catheters vigorous flushing of the cervical canal and the routine use of antibiotics has not been established.
RCTs have shown that ultrasound guided embryo transfer ,a trial transfer prior to the actual procedure and depositing the embryos 2 cm below the uterine fundus are associated with higher pregnancy rates.
Bed rest and sexual intercourse do not affect the results.
Human Rep ,17,2002.
Introduction of ICSI in 1991 by Palermo revolutionised male factor infertility.
Arthur Kostler said “ the more original a discovery ,the more obvious it seems afterwards” ,the technique of ICSI today appears so obvious that it is hard to believe it took decades to master it.
Poor sperm motility
Low sperm count
Abnormally high amount of morphologically atypical sperms
Experienced fertilization failure in a previous IVF cycle due to unknown reason
Somatic cell nuclear transfer
Cryopreservation serves as potential
“ reproductive insurance ”
Discovery of cryo protectants in a London laboratory.
1940 s- Audrey Smith successfully stored spermatazoa at - 80 degree using glycerol as cryo protectant.
New generation cryo protectants - dimethylsulfoxide ethylene glycol and propylene glycol.
Aggressive chemotherapy and radiotherapy, as well as bone marrow transplantation, results in >90% cure in many cancers of children and young women
Ovarian tissue cryopreservation and transplantation has emerged against this background
Belgian day-old baby Tamara Bouanati nestles in the arms of her mother Ouarda Touirat, 32. Touirat beat cancer and gave birth after an ovarian tissue transplant
Ovarian tissue banking
Orthotopic transplant –resumption of cyclicity – conception.
Hetrotopic transplant –autograft
Storage of eggs and embryos
Plausible explanations for difficulty of storing human oocytes -
Zona pellucida hardens during the process
Premature cortical granule exocytosis.
Spindle is a dyanamic structure – depolymerization of the spindle apparatus.
STILL EXPERIMENTAL !
Only in limited number of cases.
Transfer of mtDNA - inheritance ?
Recipient offsprings receive - nDNA + mtDNA
Potential interaction between nuclear and mitochondrial
Genome needs to be understood
STEM CELL THERAPY
Make the decisions now
even if action is future
SOURCES OF STEM CELLS
Embryonic Stem Cells
Embryonic Germ Cells
Adult Stem Cells
STEM CELL THERAPY
THE ANSWER TO DONOR ORGAN
Though stem cell science is still in infancy yet it promises clinical application in various debilitating and disabling disorders -- diabetes ,neurodegenerative diseases etc.
Most fascinating area of biology today.
Stem cell based transplantation
Unlimited supply of pleuripotent stem cells
Possibility of “universal donor cells”.
Stem cells may serve as vehicles for gene therapy.
Somatic cell nuclear transfer into enucleated oocytes followed by creation of an embryo.
Will the cloning doctors go from villains to heroes?
A thorough introduction of genetic services into the infertility management program is the need of the future
Problems are a sign of life –
the only people who have no problems are in cemeteries.