This slide explains the various important factors of infertility treatment.

2. Seed, Soil & Beyond
Dr Kaberi Banerjee
New Delhi

3. Seed
Oocyte + Sperm
=
Embryo

4. Oocyte Scoring
 Cumulus-oocyte complex scoring
 Binary score (0 or 1)
 ‘Good’ COC (score of 1) - expanded cumulus and a
radiating corona
 Zona pellucida scoring
 Colour or thickness of the zona pellucida.
 Perivitelline space - Presence of inclusions
 Polar body scoring
 Presence or absence of the first polar body
 Size of the polar body (Abnormally large polar body - risk
of oocyte aneuploidy
 Cytoplasm scoring – Check for ‘granularity’ of
cytoplasm
 Vacuolization - Large vacuoles (>14 microm in
diameter) - fertilization failure.

5. Sperm related factors
 Sperm structural defects
 Sperm DNA damage

6. Sperm structural defects
 Defect can occur in
 Head (vacuoles)
 Acrosome (agenesis - “globozoospermia” )
 Midpiece
 Tail
 Evaluate by transmission electron microscopy
(TEM)
 Inform fertilizing competence of sperm
 Identify potentially inheritable genetic
disorders (primary ciliary dyskinesia,
Kartagener’s syndrome)

7. Sperm DNA damage
 Sperm DNA
Fragmentation - breaks
in DNA double strand
due to agressions

8. Sperm DNA fragmentation
 Occur in
 Infection or inflammatory of genital tractus
 Varicocele
 Testicular maldescent
 Impaired spermatogenesis
 Radiotherapy or chemotherapy
 Exposition to heat, chemical products
 Idiopathic

9. Sperm DNA fragmentation
Tests
 TUNEL
 Comet
 CMA3
 in-situ nick translation
 DBD-FISH (DNA breakage detection fluorescence in situ
hybridization)
 Sperm chromatin dispersion test (SCD)
 SCSA

10. Embryo Assessment
 Assessing fertilization and zygotes (Day 1)
 Assessing cleavage-stage embryos (Days
2&3)
 Assessing morulae and blastocysts (Days 4 –
6)

12. Fertilization check - Pronuclear
size and location

13. Cleavage-stage embryos
 Assessment of cell number
 Fragmentation
 Extracellular membrane-bound cytoplasmic
structure that is <45 microm diameter in a Day-2
embryo and <40 microm diameter in a Day-3 embryo
 Mild (<10%); moderate (10–25%) and severe (>25%)
 Multinucleation
 Cell size
 Other morphological features of Day-2 and -3
embryos
 Cytoplasmic granularity, membrane appearance and
presence of vacuoles

14. Cleavage-stage embryo scoring
system

15. Day 4 assessment (Morula stage)

16. Day 5 assessment (Blastocyst
stage)

17. Non-viable embryo
 Embryo in which development has been
arrested for at least 24 h
or
 Embryo in which all the cells have
degenerated or lysed

18. Embryoscope - Time-lapse
analysis
 Novel non-invasive method
 Dynamic morphometric assessment
 Monitor embryo development continuously
 Allows precise measurement of 1st
cleavage time, PN fading
 Prevents from taking the dishes out of the
incubator

19. Embryoscope

20. Embryo Metabolism
 Predictor of reproductive potential
 Pyruvate and lactate metabolism
 Glucose metabolism
 Amino acid metabolism

23. Improving Seed ( Oocyte)
 Age
 Good stimulation drugs and protocols
 DHEA
 Arginine

24. Improving Seed (Sperm)
 Antibiotic treatment
 Anti oxidants
 Zinc
 Selenium
 Varicocele Surgery
 ICSI
 IMSI

25. Improving Seed (Embryo)
 Preimplantation genetic
screening
 Blastocyst transfer
 Assisted hatching
 Zygote intra-Fallopian
transfer
 Co-culture

26. Pre-implantation genetic
diagnosis (PGD)
 Genetic analysis of a
single cell from an
embryo done in
conjunction with in vitro
fertilization (IVF)
 Genetic counseling
before procedure

27. PGS indications
 Recurrent miscarriages
 One child already affected with a genetic disease
 Family history of inherited disease
 Maternal age older than 38
 Prior failure with IVF

28. PGD Method
 Ovulation Induction with drugs
 Egg Retrieval
 Fertilization
 Biopsy
 Unfertilised and fertilised oocytes (for polar
bodies, PBs)
 On day three cleavage-stage embryos (for
blastomeres – Preferable)
 On blastocysts (for trophectoderm cells)
 Genetic Analysis (FISH, PCR)
 Embryo Transfer

30. PGD Risk
• Low birth weight; premature birth
• Developmental delays
• Cognitive problems (ADHD)
• Urogenital problems
• Cerebral palsy
• Certain cancers (e.g., Beckwith-Weidemann syndrome,
which may be related to ICSI)

31. Soil
Endometrium

32. Embryo implantation
 Three-stage process
 Apposition
 Adhesion
 Invasion

33. Endometrial receptivity
 Depends upon
 Uterine cavity
abnormalities/patholog
ies
 Endometrial thickness
 Altered expression of
adhesive molecules
 Immunological factors

34. Uterine
abnormalities/pathologies
 Uterine abnormalities
 Hyperplasia
 Polyps
 Endometritis
 Synechiae
 Leiomyoma

36. Endometrial Lining
 Endometrial thickness
 Endometrial volume
 Endometrial pattern
 Uterine artery blood flow
 Endometrial / subendometrial blood
flow

41. Cellular adhesion molecules
 Hormones - Progesterone and estrogen
 Integrins, Selectins , Cadherins, Intercellular
adhesion molecule-1, Mucins
 Cytokines (Leukemia inhibitory factor, IL-6, IL-
11)
 Prostaglandins
 Growth factors (Transforming growth factor-
beta, Epidermal growth factors, Heparin
binding-epidermal growth factor, Insulin-like
growth factors)

43. Immunological factors
 Natural Killer (NK) Cells – Uterine
 Cytotoxic Lymphocytes (CTLs)
 Antithyroid Antibodies (ATA)
 Alloimmune Implantation Dysfunction:
HLA compatibility; HLA‐G and DQ‐alpha
 Antiphospholipid antibodies (lupus
anticoagulant and the anticardiolipin
antibodies)
 Autoimmune Response to Sperm Antigen


46. Endometrial Receptivity Array
(ERA) Genetic test to diagnose state of
endometrial receptivity in window of
implantation
 Analyse expression levels of 238 genes
related to status of endometrial
receptivity
 Recommended for younger women with at
least 3 failed embryo transfers or for
patients 37 years or more with 2 failed
embryo transfers

47. Endometrial Receptivity Array
 Endometrial biopsy –
 Natural cycle at day 21 i.e 7 days after LH surge
LH+7 or 6 days after the follicle rupture, when
monitored by ultrasound)
 Hormone replacement therapy cycle after 5 full
days of progesterone impregnation in HRT cycles
 After biopsy - immediately introduced into an
“ERA cryotube” containing fluid that allows
preservation of tissue

48. ERA – Interpretation
 Receptive (R):
 Gene expression profile corresponds to a normal receptive
endometrium.
 Recomended to proceed with embryo transfer at the
indicated WOI
 Non Receptive (NR):
 Gene expression profile does not correspond to normal
receptive endometrium.
 Not recomended to proceed with embryo transfer at the
indicated WOI and a personalization of the WOI is advised

50. Improving Soil
 Hysteroscopic correction of cavity
pathology
 Myomectomy
 Treatment of thin endometrium (High-
dose estrogens, low-dose aspirin &
vaginal sildenafil,arginine)
 Endometrial stimulation (biopsy) -
pseudo-decidual reaction
 Immunotherapy (intravenous
immunoglobulin, steroids, aspirin and
heparin)
 Changing day of transfer

51. Beyond
Other factors

52. Other factors
 Endometriosis
 Hydrosalpinges
 Optimum laboratory conditions
 Embryo transfer techniques
 Adjunctive treatment
(Metformin, Bromocriptine,
Thyroxine)
 Alternative treatment

53. Endometriosis
 Leads to
 Distorted pelvic
anatomy
 Impaired ovary
function
 Altered
microenvironment
 Affects endometrial
receptivity
 Reduced oocyte/
embryo quality

54. Hydrosalpinx
 Fluid causes
 Mechanical effects
 Embryo and gametotoxicity
 Alterations in endometrial receptivity
markers, resulting in poor implantation
 Direct effect on the endometrium, leading
to intrauterine fluid formation

56. Multifactorial treatment
options
 Treating endometriosis – Laparoscopic approach
 Salpingectomy in case of hydrosalpinges
 Tailoring the stimulation protocols – Use of GnRH-
antagonist protocol
 Psychological assistance
 Embryo transfer techniques
 Adjunctive treatment (Metformin, Bromocriptine,
Thyroxine)
 Alternative treatment

59. Conclusion
For successful embryo implantation
 Select best embryo (Seed)
 Identify good endometrium (Soil)

60. Thank you