ART refers to methods used to achieve pregnancy by artificial or partially artificial means. • INCLUDES- artificial insemination, In vitro fertilization (IVF) , Zygote intrafallopian transfer (ZIFT) or Tubal Embryo Transfer, Gamete intrafallopian transfer (GIFT) , Intracytoplasmic sperm injection (ICSI)

2. ART refers to methods used to achieve
pregnancy by artificial or partially
artificial means.

3. INFERTILITY
 refers to the biological inability of a person to
contribute to conception
 The term "primary infertility" is applied to the
couple who has never achieved a pregnancy.
 “Secondary infertility" implies that at least one
previous conception has taken place.

4. CAUSES OF INFERTILITY IN A
COUPLE
 SEXUAL DYSFUNTION
 MENTAL OR PHYSIOLOGICAL FACTOR
 IMMMUNOLOGICAL INCAPIBILITY
 GENETIC ABNORMALITY
 INFECTIOUS DISEASES
 NUTRITIONAL FACTORS
 TRAUMA OR SHOCK
 RADIATION
 DRUG USE
 ENDOCRINE FACTORS
 ENVIRONMENTAL POLLUTANTS OR INDUSTRIAL HAZZARDS

5. Female Infertility
Physical
Obstructions
hormonal
Obstructions
Development
Problems
Fertilization
Problems
Endometriosis
•Pelvic
Inflammatory
Disease
•Uterine Fibroids
•Pelvic
Adhesions
•Hard Eggs
•Teratogens
•Ovulation disorders
•Elevated prolactin
•Polycystic ovary
syndrome
•Early menopause
•Anti-sperm
antibodies (ASA)
•Oocyte
membrane
proteins

6. Physical Obstructions characteristics
Endometriosis •(endo, "inside", and metra, "womb")
• endometrial-like cells appear and flourish in
areas outside the uterine cavity, most commonly
on the ovaries
• can block the fallopian tubes and prevent the
egg from entering the uterus.
•There is a 25-35% rate of infertility in moderate
to severe cases of Endometriosis
Uterine Fibroids
•Fibroids are muscular tumors that grow in the
wall of the uterus .also called "leiomyoma" or
just "myoma".
•always benign (not cancerous)
• three groups :
•Submucosal :fibroids grow into the uterine
cavity.
•Intramural :fibroids grow within the wall of the

7. Pelvic inflammatory disease (PID) • It is infection of the female
reproductive organs especially the
fallopian tubes, Uterus and ovaries.
•CAUSES
 (STDs) caused by Chlamydia and
Gonorrhea
bacteria may also enter the body
during
Childbirth, Endometrial biopsy
,Insertion of an (IUD)
• Complications:
 Ectopic pregnancy
Pelvic Adhesions • bands of scar tissue that bind organs
after pelvic infection, appendicitis, or
abdominal or pelvic surgery.
•If present:
•fallopian tubes :block an egg from
entering the fallopian tube or FT
partially blocked by adhesions
fertilized egg but may not reach
uterus; ectopic pregnancy

8. Hormonal Obstructions characteristics
1)Ovulation disorders •infrequent or absent ovulation
(anovulation), typically result in
infrequent periods (oligomenorrhea).
• cause d due low levels of luteinizing
hormone (LH) and follicle-stimulating
hormone (FSH).
2)Elevated prolactin •Also called hyperprolactinemia
•Can cause irregular or no ovulation
•Irregular periods
•May cause galactorrehea, milk
production when not pregnant
3)Polycystic ovary syndrome •With PCOS, ♀ typically have:
•high levels of androgens
•missed or irregular periods
•many small cysts in their ovaries (fluid-
filled sacs).
• most common cause of ♀ infertility
4)Early menopause Early depletion of ovarian follicles before

9. Development Problems characteristics
Anti-sperm antibodies (ASA) •The developing embryo may be
miscarried due to the mother’s
immune system recognizing it as a
“foreign body” and attacking it.
•♀ may also produce (ASA) to her
partner’s sperm.
•ASA neutralize sperm by clumping
them together and destroying their
membranes. Cause reduce their
motility
•Impede progression of the sperm
through cervical mucus
•Interfere with the sperm/egg binding
process
•An estimated 12 to 15 percent of
unexplained infertility in women is
linked to ASA
Oocyte membrane proteins •Receptin, an oocyte membrane
protein, is responsible for binding
sperm with the egg.
•If this protein is not receptive or
present, fertilization cannot occur.

10. The Age Factor
 A woman's fertility naturally
starts to decline in her late
20's.
 After age 35 a woman's
fertility decreases rapidly.
 A woman is born with all the
eggs she'll have, and with
time, the supply diminishes.
 The remaining eggs also age
along with the rest of the
body.

11. Male Infertility
 Abnormal sperm production - One of the most common causes of infertility
in men
 Low sperm concentration - Low sperm concentration, known as sub-fertility, is
defined as 10 million or less sperm per milliliter of semen. The count for normal
sperm concentration is greater than or equal to 20 million sperm per milliliter of
semen.
 Blockage of sperm delivery .
 Testicular Varicocele - A varicocele is a dilated or varicose vein and when it
occurs in the scrotum it may prevent normal cooling of the testicle. This leads to
reduced sperm count and motility
 Undescended testicle or testes
 Hormonal problems - If the pituitary gland, which is situated at the base of the
brain, does not send the correct signals to stimulate the testes, low testosterone
levels may be caused. Because of this sperm cannot be produced.
 Underlying medical conditions - An existing medical condition such as thyroid

12.  Genetic defects - In the genetic defect Klinefelter's syndrome, a
man has two X chromosomes and one Y chromosome instead of
one X and one Y. This causes abnormal development of the
testicles, resulting in low or absent sperm production.
 Age - A man’s fertility declines as he ages. It has been estimated
that the amount of semen ejaculated and sperm motility begins to
slowly decrease in men or from the age of 37 years.
 Tobacco smoking
 Alcohol
 Recreational drugs
 Sexually transmitted diseases (STDs) - gonorrhea and genital
herpes can affect sperm production and damage the epididymis,
preventing sperm from passing from the testes to ejaculate.

13. Assisted Reproductive
Technologies (ART)
artificial insemination
In vitro fertilization (IVF)
Zygote intrafallopian transfer
(ZIFT) or Tubal Embryo Transfer
Gamete intrafallopian transfer
(GIFT)
Intracytoplasmic sperm injection
(ICSI)
1
2
3
4
5

14. Artificial Insemination (AI)
 the introduction of semen into the vagina or uterus by mechanical or
instrumental means rather than by sexual intercourse.
 The procedure is planned to coincide with the expected time of
ovulation so that fertilization can occur.
 Kinds of artificial insemination are artificial insemination-donor
(AID) and artificial insemination-husband (AIH).
 Pregnancy rates are lower when insemination is used:
 in women over 38 years old
 in women with low ovarian reserve
 with poor quality sperm
 in women with moderate (or severe) endometriosis
 in women with any degree of tubal damage or pelvic scarring

15. How is insemination performed? What is the
process for artificial insemination in
humans?
.
woman usually is given medications to stimulate
development of multiple eggs and the insemination
is timed to coincide with ovulation - release of the
eggs.
A semen specimen obtained either from donor or
husband.
sperm washing performed which separates sperm
from the other components of the semen and
concentrated in a small volume. Sperm processing
takes about 30-60 minutes.
A speculum is placed in the vagina and the cervical
area is gently cleaned.
The washed specimen of highly motile sperm is
placed either in the cervix (intracervical
insemination, ICI) or higher in the uterine cavity
(intrauterine insemination, IUI) or fallopian tube
using a sterile, flexible catheter.

16. Intrauterine
insemination (IUI): An
efficient method of
insemination involving
direct insertion of sperms
into woman’s uterus with
the help of a catheter.
Insemination can be performedthrough 3 major
techniques:

17. Intracervical insemination
(ICI):
 easiest way to
inseminate.
 involves the deposit of
raw fresh or frozen semen
(which has been thawed)
by injecting it high into the
cervix with a needle-less
syringe.
Intratubal
insemination:
Insertion of sperm
directly into the fallopian
tube.

18. Some of the potential risks and effects of
artificial insemination are:
 Minor cramping and lower abdominal pain for a short
period of time following the AI procedure.
 Continued vaginal bleeding or spotting.
 Infection in the uterus and/or fallopian tubes from
contaminated semen or a non-sterile catheter used
during the procedure.
 Disease transmitted from improperly screened semen.

19. potential risks and effects of artificial
insemination continued……
 Multiple pregnancies
 Ovarian hyperstimulation may lead to ovarian cysts, pain,
and swelling of the abdomen.
 drug side effects, such as hot flushes, depression,
headaches, irritability and night restlessness.
 Perforated uterus, if excessive force is used in inserting the
catheter during insemination.

20. In Vitro Fertilization
 In vitro means “outside the body.” egg
cells are fertilized by sperm cells outside
the mother’s womb (in vitro). The
resulting embryos are then transferred
back into the uterus.
 Walter Heap – late 19 th century
credited with first successful transfer of
embryos flushed from oviducts of one
species of rabbit to another.
 In 1959 Chang successfully carried out
IVF with rabbit oocytes and sperm.
 In 1960 Steptoe and Edwards achieved
human pregnancy, unfortunately turned
out to be ectopic.
 1978 Louise Joy Brown, first IVF
baby

21. Who should be treated with in vitro
fertilization?
 Blocked fallopian tubes or pelvic adhesions with distorted
pelvic anatomy.
 Male factor infertility(low sperm count or low motility).
 Failed 2-4 cycles ovarian stimulation with intrauterine
insemination
 Advanced female age - over about 38 years of age.
 Reduced ovarian reserve, which means lower quantity (and
sometimes quantity)
 Severe endometriosis
 Unexplained infertility (Unexplained infertility means
standard fertility tests have not found the cause of the
fertility issue).

22. STEPS OF IVF:
 Medicines, commonly called fertility
drugs(Clomiphene), are given to the woman to boost
her egg production.
 During this step, the woman will have regular
transvaginal ultrasounds to examine the ovaries and
blood tests to check hormone levels.
Step1)Stimulation, also called super ovulation

23.  A minor surgery, called follicular aspiration, is done to remove the eggs
from the woman’s body.
 Using ultrasound images as a guide, a thin needle is inserted through the
vagina into the ovary and sacs (follicles) containing the eggs.
 The needle is connected to a suction device, which pulls the eggs and fluid
out of each follicle, one at a time.
 The procedure is repeated for the other ovary.
 If a woman does not or cannot produce any eggs, donated eggs may be
used.
Step 2: Egg retrieval

24.  The man’s sperm is placed together with the best quality eggs and stored in
an environmentally controlled chamber.
 usually within few hours fertilization takes place.
 If chance of fertilization is low intracytoplasmic sperm injection (ICSI) us
used.
Step 3: Insemination and Fertilization
ICSI
(A) egg retrieved (B) the eggs are combined with
sperm in a Petri dish (C)placed in an incubator. (D
If fertilization occurs, the embryos are transferred
by means of a fine, ultrasound-guided cannula
(E)transferred to uterus.

25.  When the fertilized egg divides, it becomes an embryo.
 Laboratory staff will regularly check the embryo to make sure it is
growing properly. Within about 5 days, a normal embryo has several
cells that are actively dividing.
 Couples who have a high risk of passing a genetic (hereditary) disorder
to a child may consider pre-implantation genetic diagnosis (PGD).
Step 4: Embryo culture
PGD
Removal of one cell for testing

26.  Embryos are placed into the woman’s womb 3 - 5 days after egg retrieval
and fertilization.
 In The procedure a thin tube (catheter) is used.
 Assisted Hatching (AH) – technique is used to improve the probability of
the embryo’s implantation, involves the opening a small hole in the outer
membrane known as the zona pellucida either through laser or weak acid. of
the embryo which improves the ability of the embryo to leave its “shell” and
implant into the uterine lining.
 Unused embryos may be frozen and implanted or donated at a later date.
Step 5: Embryo transfer
Assisted Hatching (AH)

27. Risks of ivf:
 IVF requires a significant physical, emotional, financial, and time
commitment.
 A woman taking fertility medicines may have bloating, abdominal pain,
mood swings, headaches, and other side effects. Many IVF medicines
must be given by injection, often Repeated injections can cause bruising.
 sometimes fertility drugs may cause ovarian hyperstimulation syndrome
(OHSS). This condition causes a build up of fluid in the abdomen and
chest.
 Risks of egg retrieval include reactions to anesthesia, bleeding, infection,
and damage to structures surrounding the ovaries, including the bowel
and bladder.
 There is a risk of multiple pregnancies when more than one embryo is
placed into the womb. Carrying more than one baby at a time increases
the risk of premature birth and low birth weight.

28. Zygote intrafallopian transfer (ZIFT) or
Tubal Embryo Transfer
 similar to in vitro fertilization BUT fertilized embryo is
transferred into the fallopian tube instead of the uterus.
 also referred to as tubal embryo transfer (TET)
 Not for (Tubal blockage ,Significant tubal damage and
anatomic problem with the uterus, such as severe intrauterine
adhesions )
zygote intra-fallopian tube transfer- where the eggs are fertilized outside the body and as soon as fertilization is
visibly documented, the less than 24 hour old embryos are transferred into the fallopian tube

29. What are the similarities and differences
between ZIFT and in vitro fertilization (IVF)?
 ZIFT and IVF both involve
embryo culture.
 ZIFT and IVF both provide
the physician with the
opportunity to select only
the best quality embryos for
transfer.
 ZIFT transfers the
fertilized embryo into the
fallopian tube whereas
the IVF and embryo
transfer procedure
places the fertilized
embryo into the uterus.
 The ZIFT procedure
differs from IVF in that
the transfer of embryos
into the tube requires an
extra surgical procedure
called a laparoscopy.

30. GIFT (Gamete Intra-Fallopian Transfer)
 Gametes are washed and placed via a catheter directly into
the woman's fallopian tubes.
 This usually involves a minor surgical procedure which allows
you to go home the same day with a minor degree of pain
that lasts for just a few days.
 With GIFT, fertilization occurs inside the woman's body (not
outside), and mimics the way a normal fertilization.

31. What are the differences between GIFT and in
vitro fertilization (IVF)?
 GIFT tends to be a favorable approach for women who have
a chance of getting pregnant through other means but have
not been successful, whereas IVF is more appropriate for
women who have more severe infertility concerns.
 GIFT does not involve embryo culture. This enables some
patients to pursue additional fertility treatments without
addressing the ethical concern about how many embryos to
create or transfer.
 IVF provides your physician with the opportunity to select only
the best quality embryos on day 3 or day 5 for transfer,
whereas GIFT places unfertilized eggs and sperm in the
tubes.
 In the GIFT procedure, the transfer of gametes into the tube
requires an extra surgical procedure called laparoscopy.

32. Intracytoplasmic Sperm Injection (ICSI)
 Intracytoplasmic Sperm Injection (ICSI) is an assisted reproductive
technological procedure performed under a microscope, which aids in
the introduction of a single sperm into the cytoplasm of an egg.
 Intracytoplasmic Sperm Injection (ICSI) has been performed since
1991 (Palermo et al, 1991)

33. Common reasons used for performing
ICSI
 Severe male factor infertility that do not want donor sperm
insemination.
 Couples with infertility with:
 Sperm concentrations of less than 15-20 million per milliliter
 Low sperm motility- less than 35%
 Very poor sperm morphology (subjective - specific cutoff value is
debatable)
 Failed IVF with no fertilization - or a low rate of fertilization.
 Sometimes it is used for couples that have a low yield of
eggs at egg retrieval.

34. I
needle
How is ICSI performed?
2) 3)
1) 4)
5)
Normally fertilized egg 1 day after retrieval

35. Advantages of ICSI over IVF
 ICSI can be performed for men who have very few numbers of
sperm in their semen, too few for IVF.
 It can be performed for those men whose sperm have minimal
activity which would be too slow for IVF
 There is usually a higher fertilization rate, therefore, couples have a
higher number of embryos to transfer, than would be the case with
IVF
 There can be a reduction in the number of eggs fertilized by more
than one sperm.
 There is the option of using the male partner's sperm instead of