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Pritam PrajapatiPritam Prajapati
B.Tech in Biotechnology
5th
Sem
ASHOKA INSTITUTE
OF TECHNOLOGY & MANAGEMENT
VARANASI
Introduction
A woman of reproductive age who has not conceived
after 1 year of unprotected vaginal sexual intercourse, in
the absence of any known cause of infertility, should be
offered further clinical assessment and investigation
along with her partner.
Offer an earlier referral for specialist consultation to
discuss the options for attempting conception, further
assessment and appropriate treatment where –
- the woman is aged 36 years or over
- there is a known clinical cause of infertility or a
history of predisposing factors for infertility
NICE Guidelines 2013
Multiple relatively minor abnormalities, either with 1 partner or both,
account for 30% of all causes
Main Causes of Infertility
Assisted Reproductive Techniques (ART)
Any treatment that deals with “means of conception
other than vaginal intercourse” is termed as ART.
NICE guideline 2013
IUI – Intra Uterine Insemination (Husband /
Donor)
IVF + ET – In Vitro Fertilization + Embryo transfer
ICSI – Intra Cytoplasmic Sperm Injection
IUI
• Injection of washed prepared sperms into
the uterine cavity through a fine catheter
during peri-ovulatory phase in a natural
or stimulated cycle.
• Although pregnancy may not occur as quickly, a policy of
initial treatment by IUI will probably save 20% of couples
from moving onto IVF
• After 3-4 cycles of failed IUI treatment, patients should
be encouraged to opt for IVF
The procedure may help in increasing the chances of
pregnancy in following ways –
1.Allowing sperm-ovum contact close to the date and time of
ovulation
2.By bringing the sperm very close to the site of fertilization
and by passing the cervical factors
3.Sperm preparation increases the sperm density and removes
all antigens on the surface of sperm and in seminal plasma
-IUI is the simplest and the least expensive method of
ART
-IUI alone (natural cycle) does not improve pregnancy
chances, hence mild ovarian stimulation is usually
recommended.
IUI
Indications for Intra Uterine Insemination (IUI)
- At least one Fallopian tube must be normal and
patent
- Mild male infertility
- Unexplained infertility
- Ovulatory dysfunction, PCOS
- Mild endometriosis
- Cervical factors
- Coital problems
- Immunological factors
- HIV, HBs Ag infection
- Donor Sperm
Indications for Donor Sperm IUI
Azoospermia (where ICSI is not an option)
Severely subnormal semen parameters
(ICSI not an option)
Persistent failure of ICSI
Rh Isoimmunization
Hereditary disease in the male partners
Indication for ART – IUI or IVF
 The indications for IUI are often
not dissimilar to those for IVF (or
even for ICSI for moderate male
factor) and often interchangeable
with overlapping.
Common Indications for IUI Indications for IVF
-Unexplained infertility - Unexplained infertility
-Endometriosis (mild) - Endometriosis (moderate to severe)
-Male factor infertility (mild) - Male factor infertility (moderate to
severe)
-Ovulatory disorders - Ovulatory disorders
-Inability to have vaginal intercourse
-People with conditions that require - Tubal pathology
specific consideration (such as man HIV - Donor Oocyte
positive) - Genetic Surrogacy
- People in same-sex relationship - PGD (Possibility of genetically
- Donor Sperm transmitted disease)
- Fertility preservation in cancer
patients
- Where ICSI is indicated
(Azoospermia)
Meta-Analysis of IUI in Male Factor
Pregnancy Rate
Timed intercourse in natural cycle 2.4%
Timed intercourse in COH cycle 5.0%
IUI in natural cycle 6.5%
IUI in COH cycles 12.6%
Cohlen BJ et al Cochrane database Syst Rev 2003
Basic requirements for IUI success
1. Patient selection
- Age of female partner < 35 years
- Duration of infertility < 5 years
- Cause of infertility (at least one functional normal
fallopian tube and no uterine factors)
- Adequate ovarian reserve (based on Serum AMH, antral
follicle count, Day 2 FSH, LH, E2 levels)
- Semen parameters Post wash TMSC >5 million/ml
Best pregnancy rates with >10 million/ml
< 1 or 2 million/ml – do not waste time in IUI.
Advice IVF / ICSI straight away
Basic requirements for IUI success contd…
2. Choice of ovarian stimulation used
3. Number of dominant follicles – 1 to 3 follicles
4. Use of “transvaginal ultrasound follicle monitoring”
5. Timing of IUI
- Between day 12 to 16 of the cycle usually highest
pregnancy rates
- Interval from hCG injection 32-42 Hours usually
recommended (range 12-60 hours)
- Single IUI 36 hours after hCG is usually the
preferred option.
6. Semen preparation technique – Quality and
expertize of lab personnel
7. Procedure of IUI & type of catheter used
8. Luteal support is recommended
9. How many IUI cycles- 3-6 cycles usually
recommended
Basic requirements for IUI success contd…
INTRAUTERINE INSEMINATION – ESHRE Guidelines
There is general agreement in the literature that chances of
success are better after mild ovarian stimulation and the
maturation of a maximum of two or three follicles.
However, the cycle must be monitored by ultrasound and
hormonal analysis; if there are more than three mature
follicles, the attempt should be cancelled.
While the concurrent use of ovarian stimulation may
increase pregnancy rates, it may be at the expense of a
high chance of multiple pregnancy.
The majority of pregnancies occur during the first six
cycles. In any case, the number of attempts should not exceed
nine cycles.
When assessing the duration of an IUI programme, the age of
the woman must be taken into account, to ensure timely
transfer to more complex treatments if indicated.
• The world's first "test-tube
baby", Louise Brown, has
spoken of her joy at giving
birth to her first child.
• Baby Cameron was born on
20 December’06 in Bristol,
where his 28-year-old mother
lives with husband Wesley
Mullinder.
Well over two million "test-tube" babies have been born globally
since Louise's 1978 birth after IVF
IVF and ET
• In Vitro Fertilization (IVF) and Embryo Transfer (ET) are the basic ART
for all related technology. These include:
- Intra Cytoplasmic Sperm Injection (ICSI)
- Assisted hatching
- Pre-implantation Genetic Diagnosis (PGD)
- Cryopreservation
- Donor oocyte IVF programs
- Donor embryo (genetic surrogacy)
- Intracytoplasmic Morphologically selected
Sperm Injection (IMSI)
- And many more
Pre IVF work-up Ovarian stimulation Monitoring
Preparation of
sperms
Oocyte retrieval
Embryo transfer Luteal Support
Ovulation induction
In Vitro Fertilization
IVF & ET
Procedure
Picture
In vitro embryo development
COC at the time of
retrieval
M II oocyte with a PB
(Mature)
2 PN embryo
4 cell embryo 8 cell embryo Fully grown blastocyst
Indication for IVF
I. IVF as first line infertility treatment
- Tubal pathology (severe, non-repairable)
- Donor Oocyte
- Genetic Surrogacy
- PGD (Possibility of genetically transmitted disease)
- Fertility preservation in cancer patients
- Where ICSI is indicated (Azoospermia)
II. IVF following failed cycles of IUI
-Usually up to six cycles of IUI with controlled ovarian
stimulation are recommended, but there are situations
where couples should move to IVF earlier.
Indicators for early referral
I. Female age
- The biological clock is the major adversary to
human reproduction
Woman’s age is the initial predictor of her
overall chance of success
NICE Guideline 2013
Live birth rates per Embryo
transfer by age (HFEA post-
October 2007 data)
II. Diminished Ovarian Reserve at any age
- AMH- anti-Mullerian hormone of less than or equal to
5.4pmol/l
-Antral Follicle Count (AFC) – Less than or equal to 4
-Day 2/3 FSH >8.9 IU/L
III.Endometriosis
IV.Moderate (more than slightly abnormal) degree of
semen quality abnormalities.
V. Tubal Compromise
NICE Guideline 2013
• Unprecedented
successful development
of ART which has
revolutionized the
management of severe
male infertility (Van
Steirte-ghen 1992)
• The procedure
involves the direct
injection of a single
sperm into the egg
cytoplasm
ICSI
Indications for ICSI
- Severe alterations of semen characteristics
- History of fertilization failure in conventional IVF
attempts
- Testicular or epidydimal sperm
- Other relative indications
Success rates following IVF / ICSI
24.7 percent clinical pregnancies of all women
who undergo IVF treatment (HFEA 2011).
50% of all embryos cultured in vitro reach
blastocysts stage by day 6.
About 15% of transferred embryos will
develop into a baby
Basics requirements for IVF/ICSI success
1. Pre – IVF work up of the infertile couple
 Clinical history
 Examination
 Investigations
 Counseling
Why necessary?
 To identify the cause of infertility and thereby prognosis
 To identify and correct associated adverse factors before treating
primary disorder
 To decide most appropriate treatment protocol
- Type of drug
- starting dosage
- expected response and problems
 To assess reproductive ageing and plan early access / resort to ART
treatments
2. To get adequate number of good quality oocytes
A. Predictors of COHS response Normal responders
Hyper responders
Hypo- responders
- Age, AMH, AFC
- Response to earlier COHS
- Basal FSH, LH, E2
- BMI, Smoking, Alcohol
- Previous Ovarian Surgery
B. Selection of COHS protocol
- Agonist versus Antagonist protocols
- Mild stimulation protocols
Basic requirements for IVF/ICSI success contd…
C. Ultrasound monitoring with power and colour
Doppler
D. Biochemical Monitoring
2. Ovulation induction
- hCG - urinary / recombinant
- GnRh agonist
3.Technique of Oocyte retrieval
4.Embryology lab quality and expertize
5.IVF or ICSI
6.Selecting best embryo (s) for transfer
7.Number of embryos transferred
8. Embryo transfer technique
9.Luteal Support
Basic requirements for IVF/ICSI success contd…
Luteal Support
Luteal Support
The transformation of mature follicle into corpus
Luteum (CL) after the release of ovum is triggered by an
optimal LH surge.
The function of CL is dependent upon continued
LH stimulation in luteal phase.
CL is an essential source of pro-fertility hormones ie
Progesterone (P), Estrogen (E) and other vasoactive and
growth factors.
Luteal Support
It is well established that the ovarian stimulation
regimens used in assisted reproduction cycles
alter the luteal phase.
Edwards et al 1980, Kolibianakis et al 2003
Ovarian stimulation causes
- an inadequate development of the endometrium
- an asynchrony between the endometrium and the
transferred embryo and
- adverse effects on endometrial receptivity
Macklon & Fraser 2000, Devroey et al 2004
Luteal Support contd…
The luteal phase defect in IVF is present whether
GnRH agonist or antagonist is used (Friedlers et al
2006).
The possible mechanism responsible may be –
- Continuation of pituitary down regulation effect
- Duration of luteal phase is shortened
- Formation of multiple CL leading to inhibition of
pulsatile LH release
- Loss of granulosa cells during oocyte retrieval
Luteal Phase Support
I. Endometrial support – complements production by CL
(i) Progesterone preparation
(ii)Estrogen preparation
II. Agents which support CL
(i) hCG
(ii)GnRH-analogue
(iii) LH
III.Newer agents which promote angiogenesis and
vascular supply
Progesterone preparations available
(i) Micronized
(a) Oral / vaginal - 200-400 mg BD
(b) Vaginal Gel (8%) - 90 mg daily
(c) Vaginal Pessary - 100-400 mg daily
(ii) Intramuscular (oil based) - 100-400 mg daily
(iii) Subcutaneous (aqueous preparation) - 25 mg daily
(iv) Synthetic – Dydrogesterone - 10 mg BD or TDS
Estrogen as an adjuvant to LPS
Estradiol valerate. Hemihydrate
- Oral (intravaginal)
- 2-6 mg/day
Micronized Estradiol
- Oral or intravaginal
- 2-6 mg/day
Transdermal Estradiol
- Patches (2 per week)
- 50-100 ugm/day
Luteal Phase Support for assisted reproduction cycles
(Cochrane Review 2011)
- Tesarik J et al 2006 published their result on 600 women
randomly assigned to receive a single injection of GnRH
agonist (0.1 mg of triptorelin) or placebo on Day 6 after ICSI.
The results showed improvement of implantation and
live birth rates.
- Van der Linder et al investigated progesterone versus prog +
GnRHagonist
- Six studies (1646 women)
- There were significant results showing a benefit from
addition to GnRH agonist to progesterone for the
outcomes of live birth, clinical pregnancy and ongoing
pregnancy.
GnRH agonist as an adjuvent to LPS
Luteal Phase Support for ART Cycles
Authors' conclusions
Cochrane review 2011 showed a significant effect in favour of
progesterone for luteal phase support, favouring synthetic progesterone
over micronized progesterone. Overall, the addition of other substances
such as estrogen or hCG did not seem to improve outcomes.
They found no evidence favouring a specific route or duration of
administration of progesterone.
It was found that hCG, or hCG plus progesterone, was associated with
a higher risk of OHSS.
The use of hCG should therefore be avoided.
There were significant results showing a benefit from addition of
GnRH agonist to progesterone for the outcomes of live birth, clinical
pregnancy and on-going pregnancy.
For now, progesterone seems to be the best option as luteal phase
support, with better pregnancy results when synthetic progesterone is
used.
Cochrane Review 2011
Nutritional Supplements and ART outcome
No definite conclusive evidence
Anti-oxidants – Vit C, E, selenium, zinc, taurine,
carotene, lycopene
Vitamins – Folate, Vit B 12
Myoinositol and D-chiro-inositol (vit B complex)
L – Arginine
DHEA
Dehydroepiandrosterone (DHEA)
supplementation
Cason and associates (2000) were first to suggest therapeutic benefits
from the supplementation of DHEA in women with diminished ovarian
reserve and suggested it may improve oocyte yields via IGF-1.
It was left to a 43 year old infertility patient in US (advised donor oocytes)
to discover their paper and self administer DHEA while undergoing
subsequent IVF cycles.
The patient underwent nine
consecutive IVF cycles and
increased oocytes and
embryo yields from cycle to
cycle, starting with one egg
and embryo, respectively, and
ending up with 17 oocytes and
16 embryos in her ninth cycle.
(Gleicher et al 2009)
While all other pharmacological agents affect follicle maturation
only during the final stage – gonadotropin – sensitive last 2
weeks, DHEA in contrast appears to affect folliculogenesis
at much earlier stages of in-vivo follicle maturation
(Gleicher N etal 2011)
DHEA has been shown to increase the number of primary,
preantral and antral follicles.
DHEA supplementation is reported to improve ovarian
response, IVF parameters and pregnancy chances. Younger
patients with POA appears to have a slight pregnancy
advantage.
Dehydroepiandrosterone (DHEA) supplementation
Cumulative pregnancy rates in women with DOR with and without DHEA
supplementation. POA patients appear to have a slight pregnancy advantage,
Barad et al 2007
Age-stratified miscarriage rates in DHEA supplemented DOR patient in
comparison to national U.S. IVF pregnancies. Gleicher et al 2009
DHEA supplementation is also shown to significantly
(50-80%) reduce the miscarriage risks in patients with
poor ovarian reserve (Gleicher etal 2007)
Treatment protocols, side effects and complications
Micronized DHEA at a dosage of 25mg TID
Effects occur relatively quickly (6-8 weeks) but peak
only after 5-6 months of supplementation.
Side effects are small and rare and primarily relate to
androgen effects – oily skin, acne vulgaris and hair
loss.
Even long-term therapy of DHEA in suggested
dosages have been demonstrated safe (Panjari M etal
2009).
However, before declaring DHEA as a wonder
drug, larger RCTs are urgently needed to confirm
the benefits.
Pritam Prajapati

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Artificial assisted reproductive techniques by pritam prajapati

  • 1. Pritam PrajapatiPritam Prajapati B.Tech in Biotechnology 5th Sem ASHOKA INSTITUTE OF TECHNOLOGY & MANAGEMENT VARANASI
  • 2. Introduction A woman of reproductive age who has not conceived after 1 year of unprotected vaginal sexual intercourse, in the absence of any known cause of infertility, should be offered further clinical assessment and investigation along with her partner. Offer an earlier referral for specialist consultation to discuss the options for attempting conception, further assessment and appropriate treatment where – - the woman is aged 36 years or over - there is a known clinical cause of infertility or a history of predisposing factors for infertility NICE Guidelines 2013
  • 3. Multiple relatively minor abnormalities, either with 1 partner or both, account for 30% of all causes Main Causes of Infertility
  • 4. Assisted Reproductive Techniques (ART) Any treatment that deals with “means of conception other than vaginal intercourse” is termed as ART. NICE guideline 2013 IUI – Intra Uterine Insemination (Husband / Donor) IVF + ET – In Vitro Fertilization + Embryo transfer ICSI – Intra Cytoplasmic Sperm Injection
  • 5. IUI • Injection of washed prepared sperms into the uterine cavity through a fine catheter during peri-ovulatory phase in a natural or stimulated cycle. • Although pregnancy may not occur as quickly, a policy of initial treatment by IUI will probably save 20% of couples from moving onto IVF • After 3-4 cycles of failed IUI treatment, patients should be encouraged to opt for IVF
  • 6. The procedure may help in increasing the chances of pregnancy in following ways – 1.Allowing sperm-ovum contact close to the date and time of ovulation 2.By bringing the sperm very close to the site of fertilization and by passing the cervical factors 3.Sperm preparation increases the sperm density and removes all antigens on the surface of sperm and in seminal plasma -IUI is the simplest and the least expensive method of ART -IUI alone (natural cycle) does not improve pregnancy chances, hence mild ovarian stimulation is usually recommended. IUI
  • 7. Indications for Intra Uterine Insemination (IUI) - At least one Fallopian tube must be normal and patent - Mild male infertility - Unexplained infertility - Ovulatory dysfunction, PCOS - Mild endometriosis - Cervical factors - Coital problems - Immunological factors - HIV, HBs Ag infection - Donor Sperm
  • 8. Indications for Donor Sperm IUI Azoospermia (where ICSI is not an option) Severely subnormal semen parameters (ICSI not an option) Persistent failure of ICSI Rh Isoimmunization Hereditary disease in the male partners
  • 9. Indication for ART – IUI or IVF  The indications for IUI are often not dissimilar to those for IVF (or even for ICSI for moderate male factor) and often interchangeable with overlapping.
  • 10. Common Indications for IUI Indications for IVF -Unexplained infertility - Unexplained infertility -Endometriosis (mild) - Endometriosis (moderate to severe) -Male factor infertility (mild) - Male factor infertility (moderate to severe) -Ovulatory disorders - Ovulatory disorders -Inability to have vaginal intercourse -People with conditions that require - Tubal pathology specific consideration (such as man HIV - Donor Oocyte positive) - Genetic Surrogacy - People in same-sex relationship - PGD (Possibility of genetically - Donor Sperm transmitted disease) - Fertility preservation in cancer patients - Where ICSI is indicated (Azoospermia)
  • 11. Meta-Analysis of IUI in Male Factor Pregnancy Rate Timed intercourse in natural cycle 2.4% Timed intercourse in COH cycle 5.0% IUI in natural cycle 6.5% IUI in COH cycles 12.6% Cohlen BJ et al Cochrane database Syst Rev 2003
  • 12. Basic requirements for IUI success 1. Patient selection - Age of female partner < 35 years - Duration of infertility < 5 years - Cause of infertility (at least one functional normal fallopian tube and no uterine factors) - Adequate ovarian reserve (based on Serum AMH, antral follicle count, Day 2 FSH, LH, E2 levels) - Semen parameters Post wash TMSC >5 million/ml Best pregnancy rates with >10 million/ml < 1 or 2 million/ml – do not waste time in IUI. Advice IVF / ICSI straight away
  • 13. Basic requirements for IUI success contd… 2. Choice of ovarian stimulation used 3. Number of dominant follicles – 1 to 3 follicles 4. Use of “transvaginal ultrasound follicle monitoring” 5. Timing of IUI - Between day 12 to 16 of the cycle usually highest pregnancy rates - Interval from hCG injection 32-42 Hours usually recommended (range 12-60 hours) - Single IUI 36 hours after hCG is usually the preferred option.
  • 14. 6. Semen preparation technique – Quality and expertize of lab personnel 7. Procedure of IUI & type of catheter used 8. Luteal support is recommended 9. How many IUI cycles- 3-6 cycles usually recommended Basic requirements for IUI success contd…
  • 15. INTRAUTERINE INSEMINATION – ESHRE Guidelines There is general agreement in the literature that chances of success are better after mild ovarian stimulation and the maturation of a maximum of two or three follicles. However, the cycle must be monitored by ultrasound and hormonal analysis; if there are more than three mature follicles, the attempt should be cancelled. While the concurrent use of ovarian stimulation may increase pregnancy rates, it may be at the expense of a high chance of multiple pregnancy. The majority of pregnancies occur during the first six cycles. In any case, the number of attempts should not exceed nine cycles. When assessing the duration of an IUI programme, the age of the woman must be taken into account, to ensure timely transfer to more complex treatments if indicated.
  • 16. • The world's first "test-tube baby", Louise Brown, has spoken of her joy at giving birth to her first child. • Baby Cameron was born on 20 December’06 in Bristol, where his 28-year-old mother lives with husband Wesley Mullinder. Well over two million "test-tube" babies have been born globally since Louise's 1978 birth after IVF
  • 17. IVF and ET • In Vitro Fertilization (IVF) and Embryo Transfer (ET) are the basic ART for all related technology. These include: - Intra Cytoplasmic Sperm Injection (ICSI) - Assisted hatching - Pre-implantation Genetic Diagnosis (PGD) - Cryopreservation - Donor oocyte IVF programs - Donor embryo (genetic surrogacy) - Intracytoplasmic Morphologically selected Sperm Injection (IMSI) - And many more
  • 18. Pre IVF work-up Ovarian stimulation Monitoring Preparation of sperms Oocyte retrieval Embryo transfer Luteal Support Ovulation induction In Vitro Fertilization
  • 20. In vitro embryo development COC at the time of retrieval M II oocyte with a PB (Mature) 2 PN embryo 4 cell embryo 8 cell embryo Fully grown blastocyst
  • 21. Indication for IVF I. IVF as first line infertility treatment - Tubal pathology (severe, non-repairable) - Donor Oocyte - Genetic Surrogacy - PGD (Possibility of genetically transmitted disease) - Fertility preservation in cancer patients - Where ICSI is indicated (Azoospermia) II. IVF following failed cycles of IUI -Usually up to six cycles of IUI with controlled ovarian stimulation are recommended, but there are situations where couples should move to IVF earlier.
  • 22. Indicators for early referral I. Female age - The biological clock is the major adversary to human reproduction
  • 23. Woman’s age is the initial predictor of her overall chance of success NICE Guideline 2013 Live birth rates per Embryo transfer by age (HFEA post- October 2007 data)
  • 24. II. Diminished Ovarian Reserve at any age - AMH- anti-Mullerian hormone of less than or equal to 5.4pmol/l -Antral Follicle Count (AFC) – Less than or equal to 4 -Day 2/3 FSH >8.9 IU/L III.Endometriosis IV.Moderate (more than slightly abnormal) degree of semen quality abnormalities. V. Tubal Compromise NICE Guideline 2013
  • 25. • Unprecedented successful development of ART which has revolutionized the management of severe male infertility (Van Steirte-ghen 1992) • The procedure involves the direct injection of a single sperm into the egg cytoplasm ICSI
  • 26. Indications for ICSI - Severe alterations of semen characteristics - History of fertilization failure in conventional IVF attempts - Testicular or epidydimal sperm - Other relative indications
  • 27. Success rates following IVF / ICSI 24.7 percent clinical pregnancies of all women who undergo IVF treatment (HFEA 2011). 50% of all embryos cultured in vitro reach blastocysts stage by day 6. About 15% of transferred embryos will develop into a baby
  • 28. Basics requirements for IVF/ICSI success 1. Pre – IVF work up of the infertile couple  Clinical history  Examination  Investigations  Counseling Why necessary?  To identify the cause of infertility and thereby prognosis  To identify and correct associated adverse factors before treating primary disorder  To decide most appropriate treatment protocol - Type of drug - starting dosage - expected response and problems  To assess reproductive ageing and plan early access / resort to ART treatments
  • 29. 2. To get adequate number of good quality oocytes A. Predictors of COHS response Normal responders Hyper responders Hypo- responders - Age, AMH, AFC - Response to earlier COHS - Basal FSH, LH, E2 - BMI, Smoking, Alcohol - Previous Ovarian Surgery B. Selection of COHS protocol - Agonist versus Antagonist protocols - Mild stimulation protocols Basic requirements for IVF/ICSI success contd…
  • 30. C. Ultrasound monitoring with power and colour Doppler D. Biochemical Monitoring 2. Ovulation induction - hCG - urinary / recombinant - GnRh agonist 3.Technique of Oocyte retrieval 4.Embryology lab quality and expertize 5.IVF or ICSI 6.Selecting best embryo (s) for transfer 7.Number of embryos transferred 8. Embryo transfer technique 9.Luteal Support Basic requirements for IVF/ICSI success contd…
  • 32. Luteal Support The transformation of mature follicle into corpus Luteum (CL) after the release of ovum is triggered by an optimal LH surge. The function of CL is dependent upon continued LH stimulation in luteal phase. CL is an essential source of pro-fertility hormones ie Progesterone (P), Estrogen (E) and other vasoactive and growth factors.
  • 33. Luteal Support It is well established that the ovarian stimulation regimens used in assisted reproduction cycles alter the luteal phase. Edwards et al 1980, Kolibianakis et al 2003 Ovarian stimulation causes - an inadequate development of the endometrium - an asynchrony between the endometrium and the transferred embryo and - adverse effects on endometrial receptivity Macklon & Fraser 2000, Devroey et al 2004
  • 34. Luteal Support contd… The luteal phase defect in IVF is present whether GnRH agonist or antagonist is used (Friedlers et al 2006). The possible mechanism responsible may be – - Continuation of pituitary down regulation effect - Duration of luteal phase is shortened - Formation of multiple CL leading to inhibition of pulsatile LH release - Loss of granulosa cells during oocyte retrieval
  • 35. Luteal Phase Support I. Endometrial support – complements production by CL (i) Progesterone preparation (ii)Estrogen preparation II. Agents which support CL (i) hCG (ii)GnRH-analogue (iii) LH III.Newer agents which promote angiogenesis and vascular supply
  • 36. Progesterone preparations available (i) Micronized (a) Oral / vaginal - 200-400 mg BD (b) Vaginal Gel (8%) - 90 mg daily (c) Vaginal Pessary - 100-400 mg daily (ii) Intramuscular (oil based) - 100-400 mg daily (iii) Subcutaneous (aqueous preparation) - 25 mg daily (iv) Synthetic – Dydrogesterone - 10 mg BD or TDS
  • 37. Estrogen as an adjuvant to LPS Estradiol valerate. Hemihydrate - Oral (intravaginal) - 2-6 mg/day Micronized Estradiol - Oral or intravaginal - 2-6 mg/day Transdermal Estradiol - Patches (2 per week) - 50-100 ugm/day
  • 38. Luteal Phase Support for assisted reproduction cycles (Cochrane Review 2011) - Tesarik J et al 2006 published their result on 600 women randomly assigned to receive a single injection of GnRH agonist (0.1 mg of triptorelin) or placebo on Day 6 after ICSI. The results showed improvement of implantation and live birth rates. - Van der Linder et al investigated progesterone versus prog + GnRHagonist - Six studies (1646 women) - There were significant results showing a benefit from addition to GnRH agonist to progesterone for the outcomes of live birth, clinical pregnancy and ongoing pregnancy. GnRH agonist as an adjuvent to LPS
  • 39. Luteal Phase Support for ART Cycles Authors' conclusions Cochrane review 2011 showed a significant effect in favour of progesterone for luteal phase support, favouring synthetic progesterone over micronized progesterone. Overall, the addition of other substances such as estrogen or hCG did not seem to improve outcomes. They found no evidence favouring a specific route or duration of administration of progesterone. It was found that hCG, or hCG plus progesterone, was associated with a higher risk of OHSS. The use of hCG should therefore be avoided. There were significant results showing a benefit from addition of GnRH agonist to progesterone for the outcomes of live birth, clinical pregnancy and on-going pregnancy. For now, progesterone seems to be the best option as luteal phase support, with better pregnancy results when synthetic progesterone is used. Cochrane Review 2011
  • 40. Nutritional Supplements and ART outcome No definite conclusive evidence Anti-oxidants – Vit C, E, selenium, zinc, taurine, carotene, lycopene Vitamins – Folate, Vit B 12 Myoinositol and D-chiro-inositol (vit B complex) L – Arginine DHEA
  • 41. Dehydroepiandrosterone (DHEA) supplementation Cason and associates (2000) were first to suggest therapeutic benefits from the supplementation of DHEA in women with diminished ovarian reserve and suggested it may improve oocyte yields via IGF-1. It was left to a 43 year old infertility patient in US (advised donor oocytes) to discover their paper and self administer DHEA while undergoing subsequent IVF cycles. The patient underwent nine consecutive IVF cycles and increased oocytes and embryo yields from cycle to cycle, starting with one egg and embryo, respectively, and ending up with 17 oocytes and 16 embryos in her ninth cycle. (Gleicher et al 2009)
  • 42. While all other pharmacological agents affect follicle maturation only during the final stage – gonadotropin – sensitive last 2 weeks, DHEA in contrast appears to affect folliculogenesis at much earlier stages of in-vivo follicle maturation (Gleicher N etal 2011) DHEA has been shown to increase the number of primary, preantral and antral follicles. DHEA supplementation is reported to improve ovarian response, IVF parameters and pregnancy chances. Younger patients with POA appears to have a slight pregnancy advantage. Dehydroepiandrosterone (DHEA) supplementation
  • 43. Cumulative pregnancy rates in women with DOR with and without DHEA supplementation. POA patients appear to have a slight pregnancy advantage, Barad et al 2007
  • 44. Age-stratified miscarriage rates in DHEA supplemented DOR patient in comparison to national U.S. IVF pregnancies. Gleicher et al 2009 DHEA supplementation is also shown to significantly (50-80%) reduce the miscarriage risks in patients with poor ovarian reserve (Gleicher etal 2007)
  • 45. Treatment protocols, side effects and complications Micronized DHEA at a dosage of 25mg TID Effects occur relatively quickly (6-8 weeks) but peak only after 5-6 months of supplementation. Side effects are small and rare and primarily relate to androgen effects – oily skin, acne vulgaris and hair loss. Even long-term therapy of DHEA in suggested dosages have been demonstrated safe (Panjari M etal 2009). However, before declaring DHEA as a wonder drug, larger RCTs are urgently needed to confirm the benefits.