This slide has been prepared for educational purpose using various standard medical books. This is prepared by medical student and if any mistakes are there please comment.

1. In Vitro Fertilization
Jeetendra Bhandari
Patan Academy of Health Sciences-School of Medicine
Medical Student

2. Introduction
• Assisted reproductive technology
• Discovered by Patrick Steptoe and Robert Edwards
• First child Louise Brown in 1978
• More than 2 million babies born till now

3. Patient Selection
• Age <35 years
• Presence of ovarian reserve(D-3, serum FSH <10 IU/L)
• Husband – normal seminogram
• Couple screened negative for HIV and Hepatitis
• Normal uterine cavity as evaluated by hysteroscopy/sonography

4. Indication
• Tubal disease
• Unexplained infertility
• Mild Endometriosis
• Multiple factor(male and female)
• Failed ovulation induction
• Ovarian failure(donor oocyte IVF)
• Women with normal ovaries but no functional uterus(Mullerian
agenesis)
• Women with genetic risk(IVF and PGD)

5. Prognostic factor
• Maternal Age (age related decline in response to ovarian stimulation,
less oocytes, poor oocyte quality, less embryos and implantation rate)
• Ovarian reserve (decline with age)
• Women with tubal or ovulatory factor, endometriosis have higher
success rate than with poor reserve
• Presence of hydrosalpinges -affect outcome adversely
• Fibroid uterus- especially sub-mucous or interstitial variety have
adverse outcome
• Smoking- poor outcome

6. Drug protocol for ovulation
induction

7. Downregulation gonadotropin-releasing
hormone (GnRH) agonist protocol
• Also known as long protocol
• combined with combination oral contraceptive (COC) pill pretreatment
• GnRH agonists begun typically 7 days prior to gonadotropins
• Serial serum estrogen levels and sonographic surveillance of follicular
development accompany gonadotropin administration
• hCG administered to trigger ovulation when sonography shows three or
more follicles measuring at least 17 mm

8. • Eggs retrieved 36 hours later
• Embryos are transferred back to uterus 3–5 days following retrieval
• GnRH agonists suppress endogenous pituitary release of gonadotropins
minimizes the risk of a premature luteinizing hormone (LH) surge and thus
premature ovulation
• Progesterone supplementation, with either vaginal preparations or
intramuscular injection, follows during the luteal phase to support the
endometrium

9. • Drawbacks of GnRH agonist therapy is induction of initial transient
gonadotropin release, which may lead to ovarian cyst formation
• COC pretreatment to prevent ovarian cyst formation

10. Downregulation GnRH agonist protocal

11. GnRH flare protocol
• Also known as short protocol
• GnRH agonists initially bind gonadotropes and stimulate follicle-
stimulating hormone (FSH) and LH release
• Initial flare of gonadotropes stimulates follicular development
• Initial surge of gonadotropins, the GnRH agonist causes receptor
downregulation and an ultimately hypogonadotropic state
• Gonadotropin injections begin 2 days later to continue follicular
growth

12. Fig. GnRH flare protocal

13. GnRH antagonist Protocal
• These agents are combined with gonadotropins to prevent premature
LH surge and ovulation
• Minimize risk of ovarian hyperstimulation syndrome (OHSS) and
GnRH side effects, such as
• hot flashes,
• headaches,
• bleeding
• mood changes.

14. Fig. GnRH antagonist Protocal

15. Procedure
• Antibiotics and progesterone given 2 days prior to oocyte collection to
prevent infection and for better implantation
• Mature oocytes from stimulated ovaries are retrieved transvaginally
with USG guidance
• Sperm and ova are combined in vitro to prompt fertilization
• If successful, viable embryos transferred transcervically into the
endometrial cavity using USG guidance
• Prior to transfer vaginal saline washing not Betadine because it affect
quality of ova
• One to two embryos are transferred

16. • Near ovulation, a transvaginal
approach under sonographic
guidance is used to harvest
eggs from the ovaries.
• These oocytes are fertilized in
vitro, and fertilized eggs
develop to the blastocyst stage
• Blastocysts are then drawn up
into a syringe and delivered
into the endometrial cavity
under sonographic guidance

18. Complication
• Multiple pregnancy
• Ectopic pregnancy(5%)
• Heterotropic Pregnancy(ectopic+uterine) 0.4%

19. Reference
• Dutta’s Gyanecology, 6th ed. Chapter 16. Infertility. P:266-270
• William’s Gynae, 2ed. Reproductive endocrinology, infertility and the
menopause.
• Shaw’s Textbook of gyanecology, 15th ed. The pathology of
conception. Chapter 17. P:197-220.

20. Thank you!!