Ayat taha ivf presentation in clinical pharmacy training

1. IN VITRO
FERTILIZATION
IVF
DR. MAJD ZARIFEH
AYAT TAHA 1172168

2. OVERVIEW
01 INDICATION
02
PREPARATION FOR IVF
03 IVF STEPS
04
TABLE OF CONTENTS
Monitoring for pregnancy Sides effect and risk
05 06

3. Infertility is defined as "a disease characterized by the failure to
establish a clinical pregnancy after 12 months of regular, unprotected
sexual intercourse.
Overview
Therapeutic interventions for treatment of male and female
infertility may involve drug therapy, surgery, and/or procedures
such as intrauterine insemination or in vitro fertilization.

4. Bromocriptine: a dopamine agonist, may be used when ovulation problems are caused by excess
production of prolactin (hyperprolactinemia) by the pituitary gland
Metformin :when insulin resistance is a known or suspected cause of infertility,
usually in women with a diagnosis of PCOS.
Clomiphene citrate. stimulates ovulation by causing the pituitary gland to release
more FSH and LH
INFERTILITY DRUGS
Gonadotropins:stimulate the ovary directly to produce multiple eggs. include human menopausal
gonadotropin ( hMG) and FSH
Letrozole :belongs to a class of drugs known as aromatase inhibitors and works in a similar fashion
to clomiphene.

5. INTRODUCTION
IVF OR test-tube conception, a complex
medical procedure in which mature egg cells
are removed from a woman, fertilized with
male sperm outside the body, and inserted
into the uterus of the same or another
woman for normal gestation
IVF

6. BLOCKED OR DAMAGED
FALLOPIAN TUBES
WOMEN WITH OVULATION DISORDERS,
PREMATURE OVARIAN
FAILURE, UTERINE FIBROIDS
INDIVIDUALS WITH A
GENETIC DISORDER
WOMEN WHO HAVE HAD THEIR
FALLOPIAN TUBES REMOVED
MALE FACTOR
INFERTILITY INCLUDING
DECREASED SPERM COUNT OR
SPERM MOTILITY
UNEXPLAINED INFERTILITY
INDICATION

7. FACTORS IMPACT IVF SUCCESS
Lifestyle factors
Cause of infertility
Reproductive history Maternal age

8. USED FOR INFERTILITY TREATMENT AND GENETIC
PROBLEMS
Fertility issues:
 Women over the age of 40
 Tubal disease (blocked fallopian tubes)
 Severe male factor infertility: azoospermia, oligozoospermia
 ovulatory dysfunction, unexplained infertility
 Diminished ovarian reserve
 Uterine factor: such as Asherman syndrome or irreparable distortion of the uterine cavity
Gender selection

9. NEGATIVE EFFECT
Poor ovarian reserve
Tobacco use
Hydrosalpinx

10. Before using IVF we try less
invasive methods, such as using
drugs that stimulate egg
production OR intrauterine
insemination

11. Preparation for IVF
•Antibiotic prophylaxis
• Thromboprophylaxis
Informed consent
Semen analysis
Assessment of ovarian reserve:
• serum FSH and estradiol
•AMH
•Ultrasound

12. Preparation for IVF
Infectious disease screening
include HIV
Uterine exam: involve
sonohysterography or
hysteroscopy

13. COMPONENTS OF AN IVF CYCLE
Ovarian stimulation
Oocyte
aspiration
Fertilization Embryo transfer

14. Ovarian stimulation protocols
USED TO PRODUCE MULTIPLE MATURE FOLLICLES (8-15), RATHER THAN A
SINGLE EGG NORMALLY DEVELOPED EACH MONTH
these regimens result in higher oocyte yields as well as higher live birth
rates per IVF cycle.
selective estrogen receptor modulators, such as clomiphene or
tamoxifen
daily injections of exogenous follicle-stimulating hormone (FSH)
Human menopausal gonadotropin-releasing hormone (hMG)
spontaneous ovulation is blocked(prevention of
premature LH surge):
GnRH agonist (long-short protocols)
GnRH antagonist (short protocol
Ovarian stimulation protocols

15. Ovarian stimulation protocols
GNRH AGONIST (LONG) PROTOCOL
•Is typically chosen for those with good ovarian reserve
Pituitary suppression
•suppress pituitary LH release begins with a
GnRH agonist that is administered daily for
approximately two weeks or until down-
regulation is complete (Serum estradiol level
less than 30 pg/mL .
•A daily dose of leuprolide acetate 0.5 to
1 mg is given subcutaneously
Ovarian stimulation
hMG, FSH, or both is administered in a dose
of 150 to 450 (maximum dose) IU/day SC to
stimulate follicular growth

16. GNRH AGONIST FLARE (SHORT) PROTOCOL
Ovarian stimulation protocols
•In patients who are poor responders to ovarian stimulation, the GnRH agonist may be
administered in conjunction with ovarian stimulation
•Regimen –a low-dose of leuprolide 40 mcg twice daily, started on day 2 of bleeding or
three to five days after the last OCP.

17. Ovarian stimulation protocols
GNRH ANTAGONIST (SHORT) PROTOCOL
•GnRH antagonists result in more rapid pituitary desensitization than GnRH agonists.
•The GnRH antagonist protocol can be used for both good and poor responders.
•In good-responder protocols, a lower dose of
gonadotropins is used.
•Providers trigger ovulation with a GnRH agonist, which
minimizes the risk of OHSS
•In poor-responder protocols, typically the maximum
dose of gonadotropins is used in combination with an
oral agent like clomiphene citrate
In a flexible protocol, is initiated when the lead follicle is
typically around 14 mm in greatest diameter and the risk
of premature ovulation first threatens cycle cancellation.
In a fixed protocol, is administered first, starting on a
particular cycle day, usually day 6. Daily injections
of the antagonist are then continued until hCG
administration.

18. Triggers for ovulation
When the ovarian follicles are judged to be mature (two or more follicles with a mean
diameter of 18 mm or more and a serum estradiol level of 200 pg/mL
Commonly used drugs:
•Urinary and recombinant hCG preparations (A dose of 250 mcg of recombinant hCG appears to be
equivalent to the standard doses of urinary hCG (5000 to 10,000 units)
•GnRH agonist trigger is generally reserved for individuals at increased risk of OHSS
•Other options – A clomiphene/gonadotropin regimen has also been used for ovulation induction, but a
insufficient evidence to recommend its use in routine IVF practice

19. • Oocyte retrieval is typically performed by transvaginal ultrasound-guided
Follicle aspiration done 34 to 36 hours after hCG administration
• An increasing number of retrieved oocytes is associated with increasing
live birth rate (up to 15 oocytes)
•Patients are commonly given intravenous propofol for analgesia
•20-30 minute procedure
Oocyte retrieval

20. Fertilization in vitro — To achieve fertilization, recovered oocytes are mixed with
spermatozoa in a small volume of culture medium.
Fertilization in vitro

22. EMBRYO TRANSFER
• Embryos are inserted into the uterus using a catheter via the cervix
• Under ultrasound guidance, they are placed 1 to 2 cm from the top of the uterine
cavity.
• The number of embryos transferred is influenced by maternal age, the number of oocytes retrieved,
and availability of embryos
• After transfer, the catheter is checked to ensure there are no
retained embryos.

23. ● fertilization of the oocyte is confirmed by observing two
pronuclei within the zygote approximately 18 hours
after insemination
● Embryos between days 2 and 4 are called "cleavage
stage embryos. “: embryo reaches approximately 8
cells by 72 hours after egg retrieval.
● blastocyst stage is reached by approximately day 5
after retrieval
● implantation is expected by day 7 after egg retrieval,
so transfer should take place prior to this time
EMBRYO MANAGEMENT

24. ● “Hatching" is a natural process in which an embryo
expands and eventually breaks through the zona
pellucida in order to implant on the surface of the
endometrium (the lining of the uterus)
● “Assisted hatching" refers to a laboratory procedure
whereby the zona pellucida around the day 3 embryo is
mechanically or chemically opened to assist the embryo
in hatching from the zona approximately three days
later
EMBRYO MANAGEMENT

25. LUTEAL PHASE SUPPORT
•to optimize endometrial receptivity, a progesterone supplement is commonly initiated on the
day of oocyte retrieval or at the time of embryo transfer
•treatment duration has ranged from obtaining a positive or negative pregnancy test to the
end of the first trimester

26. MONITORING FOR PREGNANCY .
• Pregnancy is diagnosed by identification of rising serum hCG levels after transfer
• Initial serum hCG is usually obtained no earlier than 12 days after egg retrieval
• Onc e a positive hCG is obtained, serial hCG measurements are performed to monitor whether
the rise is normal and consistent with a developing intrauterine pregnancy.
Impact of exogenous hCG
•Negative hCG test – A negative hCG level 14 days after egg retrieval is a strong indication of a
failed IVF cycle.
• If the hCG test is positive, ultrasound evaluation of the pregnancy generally begins at six
weeks of gestational age.

27. SIDE EFFECTS
Some side effects after IVF may include:
• Passing a small amount of fluid (may be clear or
blood-tinged) after the procedure
• Mild cramping
• Mild bloating
• Constipation
• Breast tendernes
If you experience any of the following symptoms, call
your doctor immediately:
•Heavy vaginal bleeding
•Pelvic pain
•Blood in the urine
•A fever over 100.5 °F (38 °C)
Some side effects of fertility medications may include:
Headaches
Mood swings
Abdominal pain
Hot flashes
Abdominal bloating
RARE: Ovarian hyperstimulation syndrome (OHSS)

28. OVARIAN HYPERSTIMULATION SYNDROME (OHSS)
• a life-threatening complication of ovulation induction that can occur in the setting of ovulation
induction with exogenous gonadotropin therapy or IVF.
• manifestations include :massive ovarian enlargement and multiple cysts, and third-space
accumulation of fluid
• these changes rarely lead to renal failure, hypovolemic shock, thromboembolic episodes, acute
respiratory distress syndrome
• The clinical symptoms usually appear 5 to 10 days following
the first dose of the ovulatory trigger (hCG, GnRH agonist).

29. RISKS OF IVF
• Egg retrieval carries risks of bleeding, infection, and damage to the bowel or bladder.
•The chance of a multiples pregnancy is increased with the use of fertility treatment.
• Increased risk of premature delivery and low birth weight.
• the risk of ectopic pregnancy with IVF is 2-5%.
• Psychological stress and emotional problems are common, especially if (IVF) is unsuccessful.
• IVF is expensive, (The cost for a single IVF cycle can range from at least 12,000-17,000.)

30. REFERENCES
• editor. (2022, March 1). IVF – In Vitro Fertilization. American Pregnancy Association. Retrieved April
9, 2022, from https://americanpregnancy.org/getting-pregnant/infertility/in-vitro-fertilization/
•Uptodate: In vitro fertilization: Procedure