2. Objectives History of Assisted Reproductive Technologies Understand ovarian stimulation and methods of monitoring follicular development Understand oocyte retrieval methods Compare cleavage stage vsblastocyst transfer Guidelines for # of embryos transferred Review techniques of embryo transfer Review complications of ART and their prevention and treatment
3. History of ART Early 1970’s First attempt at GIFT by Patrick Steptoe & Roberts Edwards, United Kingdom Used HMG/hCG simulation and laparoscopy for egg retrieval. Transferred 1 to 2 eggs and millions of sperm into ampulla
4. History of ART 1978 2003 World's first test-tube baby Louise Brown has a child of her own 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. He was born weighing 5lb 6oz at St Michael's Hospital in Bristol just before Christmas and Louise describes him as "tiny but perfect" in an interview with The Mail on Sunday.
5. History of ART 1980s 15% per cycle pregnancy rate with natural cycle IVF 1984 Two pregnancies following transfer of frozen-thawed embryos (Zeilmaker) 1985 Transvaginal US-guided oocyte retrieval (Wikland)
6. History of ART 1990 PGD introduced, initially to screen for X-linked disorders (Handyside) 1992 Advent of ICSI (Belgium)
7. Abdulkareem Sultan Al-Olama 7 Definition of Infertility & ART 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:
9. Abdulkareem Sultan Al-Olama 9 Definition of Infertility & ART Cont’d ART refers to all techniques involving direct retrieval of oocytes from the ovary ART procedures include IVF, GIFT, ZIFT, and ICSI. The simplest ART procedure, IVF has been around for over 20 years and is perhaps the most commonly recognized ART of all procedures.
15. IVF - Indications Tubal Factor Severe male factor Diminished ovarian reserve Endometriosis Advancing age Third party reproduction Unexplained infertility
16. IVF – Current Methods Precycle Work-up Ovarian Stimulation Egg Retrieval Embryo Transfer PGD Laboratory Handling
17. Precycle Workup Assess Ovarian Reserve Day 3 FSH; AFC; CCT; AMH Assess Uterine Cavity Sonohysterogram; HSG; Office Hysteroscopy Semen Analysis Male and Female ID labs Genetic screening
18. Ovarian Stimulation Natural cycle IVF Very frequent monitoring for spontaneous surge Retrieval can occur anytime, day or night Low pregnancy rates (~15%) Low efficiency and practicality
22. Ovarian Stimulation OCP Pretreatment Prevents cyst formation by GnRH agonists, decreases cycle cancellation, increases oocyte number and fertilization rates hCG Purified Human (5,000 – 10,000 U) or Recombinant hCG (250 mcg) is given when 3 follicles are > 18 mm in average diameter Resumption of meiosis and oocyte maturation and GC luteinization
27. Assisted Hatching Various protocols have been described Partial zona dissection Acid Tyrode’s assisted hatching Laser-assisted hatching Zonapellucida thinning
30. Assisted Hatching AH does not appear to improve the pregnancy rate or implantation rate in 1st IVF attempts. It does appear to be beneficial in patients with prior implantation failures. It is unclear whether AH helps patients in FET cycles, of advanced age or with thick ZPs. There is insufficient evidence to routinely recommend AH in patients undergoing ART.
34. Indications for ICSI Moderate to severe male factor Epididymal or testicular sperm History of failed fertilization with IVF Antisperm antibodies Low egg number
35. ICSI Concerns Damage to the oocyte (meiotic spindle) Override natural safeguards that serve to prevent fertilization by abnormal sperm Transmission of paternal genetic abnormalities Sex chromosomal abnormalities Y chromosome microdeletions Karyotyping and Y chromosome deletion analysis should be offered to all men with severe male factor infertility who are undergoing ICSI.
48. Blastocyst Transfer Disadvantages More demanding of embryology lab personnel and equipment Requires modified cryopreservation and thawing protocols More cycles are cancelled due to lack of embryos to transfer (Less embryos to freeze) Increase rate of twinning
58. Anesthesia and IVF Adequate pain control is important for patient safety and comfort Wide variation in anesthetic technique amongst centers internationally. In the US, 95% of centers use conscious sedation
59.
60. Important factors to consider when choosing an anesthetic agentWhether the substance enter the follicular fluid The toxicity of the anesthetic agent
61. Anesthesia and IVF Propofol is widely used during egg retrieval procedures The safety of Propofol has been extensively described in the ART literature Follicular fluid concentrations do not appear to increase with time of retrieval (length of sedation) No difference in fertilization, cleavage and embryo cell number with Propofol
62. Anesthesia and IVF Midazolam (Versed) Most commonly used benzodiazepine for conscious sedation Minimal amounts are found in follicular fluid No adverse effect on fertilization
63. Anesthesia and IVF Patients are commonly given Versed 1 mg; Fentanyl 50 µg; Propofol 1.5-2 mg/kg. Spontaneous ventilation via face mask O2
64. Cryopreservation (Freezing) Embryos Can be frozen at any state from 2PN zygotes to blastocysts Slow freezing vsvitrification Freezing at the blast stage may enhance identification of the best oocytes for subsequent transfer ~80-85% of frozen blasts survive thawing and rexpand
65. Cryopreservation (Freezing) Sperm 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 In cases where epididymal or testicular extraction is performed, donor sperm-back up in recommended Oocytes Currently experimental
70. Ovarian Physiology A woman goes into puberty with about 400,000 eggs. During the reproductive years, usually only a single egg matures each cycle Oocytes (Millions) at birth puberty 20 weeks 6-7 weeks menopause
79. Ovarian Reserve TestingAntral Follicle Count (AFC) Ultrasound during early follicular phase 6-10 antral follicles per ovary is normal <6 total predicts poor response – ↑ FSH dose, reduced pregnancy rates AFC may be a better predictor of response than FSH
80. Abnormal (increased) 20-30 antral follicles in a PCOS ovary Antral Follicle Count (AFC) Normal – 6 to 10 antral follicles
81. AMH Recent studies suggest that AMH is a superior marker for diminished ovarian reserve as compared to d3 FSH and Antral Follicle count. AMH levels correlate well with the total developing follicular cohort as well as response to gonadotropin stimulation.
82. Pregnancy Loss Rates by Age and Ovarian Reserve Pregnancy Loss Rates (%) Age in Years Scott et al 1999
83. Pregnancy Loss Rates after + FHM by Maternal Age Effect of maternal age on pregnancy loss rates after early documentation of fetal cardiac activity by TVUS Smith & Buyalos 1996
92. Engineering 124; Spring 2003 83 Commonly, more than 100 diseases can be detected through testing, including… Hemophilia A Muscular dystrophy Tay-Sachs disease Cystic fibrosis Down Syndrome Removal of one cell for testing 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.
93. Engineering 124; Spring 2003 84 Viable and Desirable? “This information is helping parents choose which embryos they want--and which to reject as unhealthy, or merely undesirable.” (Zitner 2002)
94. Engineering 124; Spring 2003 85 Undesirable Embryos Disease Free Embryos Frozen in storage Donated to infertile couples Donated to stem cell research/usage Disease Carrying Embryos Donated to research Discarded
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
