Assisted reproduction technology

Assisted Reproduction
Technology

Presented by
Abdulkareem Sultan Al-Olama 1

Introduction
 Infertility is a very common condition
affecting approximately 13-14% of
couples in the reproductive age group.
 Although this prevalence has remained
stable over the last few years, the
demand for infertility services has
increased substantially.
 This increase is due primarily to the
Baby Boom generation entering into the
reproductive age group at a time of
highly publicized technological
advances.
Abdulkareem Sultan Al-Olama
2

Topics of Discussion
 Definition of Infertility & ART
 Common causes of infertility
 Who is eligible for ART
 Methodology of ovulation induction
 Improving SPA
 Other techniques
 Counseling couple

3

Topics of Discussion Cont’d
 Failure rate
 Cost effectiveness

4

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:

5

ART Cont’d
Month Monthly Probability Cumulative Probability
1 0.2 0.20
2 0.2 0.36
3 0.2 0.49
4 0.2 0.59
5 0.2 0.67
6 0.2 0.74
7 0.2 0.79
8 0.2 0.83
9 0.2 0.86
10 0.2 0.89
11 0.2 0.91
12 0.2 0.93
6

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.
7

Common causes of
infertility

Causes of Infertility
Cause Couples Women
Male 35% N/A
Ovulatory 15% 40%
Tubal 35% 40%
Unexplained 10% 10%
Other 5% 10%

8

Common causes of
infertility Cont’d
 Female factors
 Cervical factor
 Ovulatory factor (PCOs)

 Uterine factor (endometriosis)

 Pelvic factor

9

Common causes of
 Polycystic Ovarian Syndrome
(PCOS)
Also known as Stein-Leventhal syndrome
 Also known as hyperandrogenic chronic
anovulation is a benign disorder that
commonly results in infertility.
 PCOS is characterized by irregular
ovulation and menses, obesity, insulin
resistance, acne, and hirsutism.
 Most women with PCOS also have
ovaries filled with multiple benign cysts.

10

Common causes of
infertility (PCOS) Cont’d
 How does PCOS contribute to
Infertility?
 Impaired fertility is a prominent feature of
PCOS.
 This is believed to result from elevated
insulin levels that stimulate excess
androgen production by the ovaries.
 The androgens cause premature follicular
wasting which causes inconsistent or
absent ovulation, which is associated
with infertility.

11

Common causes of
Diagnosis: 1. Symptoms
 Irregular or absent periods

 Lack of ovulation

 Weight gain

 Hirsutism (excessive hair growth)

 Insulin resistance

 Acne

 Male-pattern balding

 Multiple small ovarian cysts-these may
be seen by an ultrasound examination
 Ancthosis nigrans (darkening of the skin
at the nape of the neck and under the
arms and breasts).
12

Common causes of
Diagnosis: 2. Blood Work/Hormonal Testing:
 Laboratory testing is important for
diagnosis but it is crucial to look
at multiple values collectively.

13

Common causes of
Diagnosis: 3. Ultrasound:
 Ultrasound of the pelvis is typically
performed when the clinician suspects
PCOS.
 If >10 cysts are found in either ovary
that are less than 10mm, this meets the
ultrasound criteria for PCOS.
Furthermore, polycystic ovaries are
typically 1.5 to 3 times the normal size.
 Just the presence of polycystic ovaries,
without symptoms and/or consistent
blood work, does not confirm a
diagnosis of PCOS.
14

Common causes of
 Treatment
 Weight Loss, Progestins, Oral
Contraceptives, Anti-Androgens,
GnRH agonists, Fertility drugs,
Surgical therapy:
 a) Ovarian wedge resection
 b) Laparoscopic ovarian drilling

15

Common causes of
 Endometriosis
 Endometriosis can be defined as a
nonmalignant disorder in which
functioning endometrial tissue is present
outside the uterus.
 The incidence of this disease ranges
from 10-15% in women between the ages
of 25 and 44 who are actively
menstruating, but it also occurs in
teenagers.
 It is estimated that 25-50% of infertile
women have this disease.

16

Common causes of
infertility (Endometriosis) Cont’d
 The incidence is higher in first
degree relatives of women with
endometriosis, which suggests that
heredity may play a role.
 In addition, there is also a higher

prevalence of the disease in
women who delay childbearing or
who are of Asian descent.

17

Common causes of
 Causes and Symptoms
 The cause of endometriosis is unknown,
however there are several theories.
 The first theory is known as retrograde
menstruation, or the movement of
sloughed endometrial tissue back
through the fallopian tubes and into the
abdominal cavity. This tissue can then
attach itself to various internal organs or
tissues outside of the uterus.
 Immune system dysfunction. It is
believed that certain women may develop
endometriosis due to deficiencies in their
immune system.
18

Common causes of
 In women without endometriosis, the
immune system destroys any ectopic
implants that may develop. However, in
women with endometriosis, there is an
altered immune response and the body is
unable to destroy the growth of the
implants.
 Furthermore, some scientists believe that
endometriosis is an autoimmune
disorder. This means that the body
makes antibodies to endometrial cells.
These antibodies may destroy the
healthy endometrium found in the uterus,
but are ineffective in destroying ectopic
implants.
19

Common causes of
 Symptoms
 Pelvic pain and cramping before
and during periods
 Pain during intercourse

 Inability to conceive

 Fatigue

 Painful urination during periods

 Gastrointestinal symptoms such as
diarrhea, constipation, and nausea

20

Common causes of
 There are other medical conditions that
have similar symptoms and should be
considered prior to making a diagnosis of
endometriosis. Conditions that may
cause generalized pelvic pain include:
 Pelvic inflammatory disease (PID)
 Pelvic adhesions
 Neoplasms (cancers), both benign or
malignant
 Ovarian torsion
 Sexual or physical abuse
 Other causes that are not gynecologic in
nature
21

Common causes of
 How does endometriosis contribute to
infertility?
 The cause of infertility is believed to
result from the scarring and adhesions
that form in the reproductive tract as a
result of inflammation.
 Scar tissue and adhesions may reduce
fertility by either obstructing or distorting
the shape of the fallopian tubes, which in
turn impedes the passage of sperm to the
egg.

22

Common causes of
 In the event that sperm do reach
the egg, they may encounter a
hostile environment unfavorable to
fertilization.
 Finally, scarring from

endometriosis may obstruct the
fallopian tubes so that if an egg is
fertilized, it may be unable to travel
to the uterus for implantation.

23

Common causes of
 Diagnosis
 One of two techniques may be used to
confirm the diagnosis of endometriosis.
Both procedures involve visualization of
the pelvic cavity in order to confirm the
presence or absence of ectopic implants.
 laparoscopy
 laparotomy
 If there are any suspected ectopic
implants, they are biopsied in order to
determine the presence of endometrial
cells.

24

Who is eligible for ART
 Women with tubal diseases
 Unexplained infertility
 Endometriosis
 Immunologic causes for infertility
 Women with premature ovarian
failure
 Individuals with male factor
infertility (e.g., abnormalities in sperm
production, function or transport or
prior vasectomy)
25

Methodology of
ovulation induction Cont’d
 Basically, this term refers to the use of
medications to stimulate your body to
produce one or more eggs.
 Ovulation induction can be as simple as
taking a daily pill or more complicated,
like injecting fertility medications and
seeing your specialist daily for necessary
monitoring. The simplest form of
ovulation induction involves taking
clomiphene.

26

Methodology of
ovulation induction Cont’d
 More potent medications, known as the
gonadotropins, are available for more
intensive ovulation induction.
 Gonadotropins are injectable
medications that are made up of a
combination of follicle stimulating
hormone (FSH) and luteinizing hormone
(LH) or just FSH alone.
 These hormones can be very helpful in
getting a woman to produce and release
her eggs.

27

Methodology of
ovulation induction
 The success of ovulation induction
in achieving a pregnancy is highly
variable. It depends on the
diagnosis, age, the medication
being used, and numerous other
factors.

28

Improving SPA

 Sperm penetration assay (SPA) is a
multi-step laboratory test that offers a
biological assessment of human sperm
fertilizing ability.

29

Other techniques
 ZIFT
 GIFT
 TEST
 POST
 ICSI
 TESE
 MESA

30

Other techniques Cont’d
 ZIFT
 Zygote Intrafallopian Transfer. ZIFT may
be recommended if the husband has
severe male fertility factor or if there has
been difficulty confirming fertilization with
past procedures. ZIFT has the
advantages of allowing fertilization to be
confirmed and it has demonstrated higher
success rates than IVF when used for the
appropriate indications.
 One disadvantage with ZIFT is that the
transfer of the zygote must be performed
through a laparoscope.
31

 GIFT
 Gamete intrafallopian transfer was
developing in 1984 as a variation of in
vitro fertilization (IVF).
 Gift is recommended when
 unexplained infertility
 infertility due to immunological factors
 endometriosis
 selected cases of male infertility
 Tubal infertility
 A requirement for the procedure is that
the female partner having at least one
open (patent) fallopian tube.
32

 TEST
 Tubal Embryo Transfer; the
placing of cleaving embryos into
the fallopian tube.
 POST
 Peritoneal Oocyte and Sperm
Transfer; the placement of oocytes
and sperm into the pelvic cavity

33

 ICSI
 Intracytoplasmic sperm injection, or ICSI,
was developed to treat couples who
previously had a very poor probability of
achieving fertilization due to the male
partner's extremely low numbers of viable
sperm.
 This treatment, when combined with in
vitro fertilization, allows these couples a
more favorable probability of achieving
conception.

34

 TESE
 Testicular Sperm Extraction
 MESA
 Microsurgical Epididymal Sperm
Aspiration

35

Counseling couple
 The use of skills that enable a client to
recognize and identify his (sic) own
problems, and the ability to help client
find his own solution or resolution.
 The Human Fertilization and Embryology
Authority (HFEA) state in their code of
practice that three sorts of counseling
must be available at licensed treatment
center. These are:
 Support counseling
 Implications counseling
 Therapeutic counseling
36

Success rates
"take home baby rate"
 One of the first questions that most
people ask is "what is the chance for
success?" The best estimate is that the
birth of a live baby occurs in
approximately 15-25% of women in
whom embryos are transferred into the
uterus.
 The 1998 nationwide live birth rate as
reported in the IVF-ET Registry, was
24.9%.
 The corresponding rate for 1989 was
14%.
37

Success rates Cont’d
 Success varies with many factors,
including the number of embryos that are
transferred.
 If one embryo is transferred, there is
approximately a 7% chance of
successful implantation; with two
embryos, the success rate increases to
18%.
 The rate peaks with the transfer of three
to four embryos. Presently, the
collection of oocytes, fertilization, and
early embryo growth are accomplished
with a high degree of efficiency.
Abdulkareem Sultan Al-Olama38

 The major hurdles to success are
implantation after embryo transfer and
early pregnancy loss. The rate of early
pregnancy loss is slightly, but not
significantly, higher with ART compared
to spontaneous conception.
 The risk of early pregnancy loss
increases with age of the female partner.
Over age 40, ART success rates decline
dramatically.
 Pregnancy complications tend to be
higher with ART pregnancies, primarily
because of the much higher rate of
multiple pregnancy.
39

 Twins occur in about 25% of ART
pregnancies versus 1-2%of spontaneous
pregnancies. The risk of more than a
twin pregnancy is less than 5%.
 To put these figures into perspective,
studies have shown that the rate of
pregnancy in couples with proven fertility
in the past is approximately 20% per
cycle. Therefore, although a figure of
15-25% may sound low, it is equal to or
greater than the chance that a fertile
couple will conceive in any given cycle.
40

Cost effectiveness

41

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Assisted reproduction technology

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