Infertility and ivf

DR NILESH KATE
MBBS,MD
PROFESSOR
ESIC MEDICAL COLLEGE, GULBARGA.
DEPT. OF PHYSIOLOGY
INFERTILITY
& IVF

OBJECTIVES
 Infertility
 Definition
 Cause
 Diagnosis
 Treatment
 IVF
 Indication
 Steps
 Variations.
Thursday, June 18, 2020

Infertility.
 Def - Infertility refers to an inability to conceive
after having regular unprotected sex.
 It is a significant social and medical problem
affecting couples world wide.
 Average incidence --15%
 Unexplained infertility constitutes about 10 % of all
cases.

Definition.
 Infertility is the failure
to achieve a birth ever a
12 months period of
unprotected
intercourse.
 Infertility is the inability
of a sexually active non
contracepting couple to
achieve pregnancy in one
year.

Defect.
20 % defect
in men
40-50 in
women.
30% in
both

Causes of infertility in men
 Low sperm count:
 Less than 10 million sperm per ml of semen.
 Normal count is 35 million sperm per ml of
semen or more.
 No sperm: - Absence of sperms in semen.

Causes of infertility in men
 Low sperm motility:
 Sperms are immotile, can not
swim.
 Abnormal sperms:
 (Unusual shape , more
difficult to move and fertilize
egg)
 Its causes are:
 Testicular infections.
 Testicular cancer.
 Testicular surgery.

Other causes.
 Hypogonadism (testosterone deficiency).
 Genetic abnormality.
 Mumps (testicular inflammation).
 Hypospadiasis.
 Chlamydia infection
 Ejaculation disorders (Retrograde ejaculation).
 Variocele (includes varicose vein in scrotum).
 Undescended testicles.
 Overheating testicles.

Causes of infertility in women.
 Ovulation disorders:
 Premature ovarian failure
(before age of 40)
 Polycystic ovary syndrome.
 Hyper-prolactinemia (in non
pregnant state)
 Poor egg quality.

 Defect in uterus &
fallopian tubes:
 Surgery.
 Sub-mucosal
fibroids.
 Endometriosis.
 Previous sterilization
treatment

 Drugs:
 NSAID’S (aspirin & ibuprofen).
 Chemotherapy.
 Radiotherapy.
 Illegal drugs.

Types.
Primary.
When a women is unable to
ever bear child
Secondary.
When a women has been
pregnant but
failure to achieve live birth
after having a live
birth previously.

Diagnosis.

Treatment.
 In males
 In females.

Treatment in males.
 Blockage of the
ejaculatory duct
 Sperms can be extracted
directly from the
testicles and injected
into an egg in laboratory.

Surgery for epididymal
blockage
 A bypass of the blockage
can be performed, called
vaso-epididymostomy
(vas deferens is re-
connected to epididymis ).

Retrograde ejaculation
 Sperms can be taken
directly from the
bladder and injected
into an egg in
laboratory.

Others.
 Premature ejaculation
or Erectile dysfunction
 Behavioral approaches
(giving suggestions) or
medications.
 Variocele
 If there is varicose vein
in scrotum, it can be
surgically removed.

Treatment in females.
• Stimulate ovulation by inhibiting
production of prolactinBromocryptine
• Given in combination (clomiphine + HMG
+ FSH)
• It stimulates follicles to ovulate
Human
Chorionic
Gonadotrophin
• To encourage ovulationClomifine

Treatment in females.
• Clients who do not respond to clomiphine.
• Especially when client with PCOS linked to
insulin resistance.
Metformin
• Controls estrogen production by ovaries.
• It stimulate ovaries to mature egg follicle.
• Ex: Gonal-F, Repronex,Follistim,(given S/C)
FSH
• Genetically engineered products. Contains
both FSH & LH.
• In case of absent ovulation due to pituitary
dysfunction
Human
Menopausal
Gonadotropin.

COUNSELING
 Deals with the
psychosocial impact of
infertility in terms of :
 Intervention,
 Treatment, and
 After-effects of both
successful and unsuccessful
treatments.

COUNSELING
 It also involves therapeutic work to help
patient cope with the consequences of
infertility & treatment.

Objectives of counseling.
 Informed consent.
 To offer coping strategies to couples.
 To facilitate decision making.
 To offer preparation for procedures.
 To help client in achieving a better quality of life.
 To provide genetic counseling.

Advantages
 Helps to deal with the emotional stress.
 Provide extra support.
 Allow the client in exploring all possible
options for family.

Advantages……
 Help the couples in overcoming the
dilemmas & deciding the right fertility
treatment.
 Explains about the infertility management &
specific treatment.

ASSISTED REPRODUCTION
TECNOLOGY (ART) - ETHICAL & LEGAL
ASPECT
 Aim –
 Is to promote the
chances of fertilization
and
 Subsequent pregnancy
by bringing the sperm
and egg close to each
other.

Invitro – fertilization.
 Is a process by which an egg is fertilised by
sperm outside the body: in vitro.
 Babies conceived as the result of IVF, are
called “Test tube babies”.

History.
1890
• The very first in vitro manipulation of eggs/ embryos was performed by Walter Heape
, when he transferred in vivo fertilized eggs from one female rabbit to another.
1959
• M.C. Chang, successfully conducted IVF in rabbits.
1969
• the journal Nature published a paper authored by R.G. Edwards, B.D. Bavister and P.C.
Steptoe: “Early stages of fertilization in vitro of human oocytes matured in vitro”
1977
• The first IVF pregnancy in human and the birth of Louise Brown

Indian history.
 Dr. Subhash Mukhopadhyay
(16 January 1931 – 19 June
1981) was a physician from
Kolkata, India, who created the
world's second and India's
first child using in-vitro
fertilisation, Durga who was
born 67 days after the first IVF
baby in United Kingdom.

Indications.
 Tubal disease. In women with blocked fallopian tubes,
IVF has largely replaced surgery as the treatment of
choice.
 Endometriosis. Patients with endometriosis, often have
tubal involvement and ovarian cysts (endometrioma).
 Ovulatory dysfunction. In patients with polycystic
ovarian disease (PCOS) and other ovulatory problems.

Indications.
 Age Related Infertility.
 In normal reproductive life, a woman's ovarian function is diminished with
age. In many cases, this reduced function can be overcome through the use
of IVF
 Male Factor Infertility.
 Azoospermia, oligozoospermia, asthenozoospermia, anti-sperm antibody.
 Preimplantation Genetic Testing (PGT).
 Genetic testing on preimplantation embryos may be indicated for patients
who are at risk for genetic disorders such as Cystic fibrosis and Thalassemia

Process.
 Initial evaluation
 Suppression of natural hormonal cycle
 Ovarian stimulation
 Collection of oocytes
 Collection of sperms
 In vitro fertilization of oocytes
 Embryo transfer

Initial evaluation
 Blood tests
 Seminal Fluid
examination
 Hysterosalpingogram
 Trans vaginal
ultrasound

Suppression of natural
hormonal cycle
 Oral contraceptive pills – each day starting cycle day 1, 2
or 3 for approximately 2-4 weeks
 Lupron / Leuprolide Acetate – GnRH Agonists. It
suppresses LH surge preventing eggs from being released
before they are mature for egg retrieval. Subcutaneous inj
every morning
 Nafarelin - GnRH Agonists, three times a day nasal spray.
 Ganirelix Acetate Injection / Cetrotide – GnRH
antagonists

Ovarian stimulation
 Produce multiple mature follicles, rather than
the single egg normally developed each month.
 Produces many good follicles to be Fertilized.
 Multiple eggs are stimulated because some
eggs will not fertilize or develop normally after
fertilization.
 Regular monitoring by ultrasound scan is
done.

Collection of oocytes
 The oocyte maturation is performed, generally by
an injection of human chorionic gonadotropin
(hCG). Commonly, known as the "trigger shot.“
 The egg retrieval is performed at a time usually
between 34 and 36 hours after hCG injection.
 Egg retrieval is usually accomplished by
transvaginal ultrasound aspiration.

Collection of oocytes
 It is done under short general anesthesia, and is 20
to 30 minutes procedure.
 In some circumstances, one or both ovaries may
not be accessible by transvaginal ultrasound.
Laparoscopy may then be used to retrieve the eggs
using a small telescope placed in the umbilicus.

Collection of sperms
 Shortly before or after the oocyte collection the
male partner will be asked to give a sperm
sample.
 Sexual abstinence of 3-4 days should b exercised.
 Collected about 60-90 minutes prior to
fertilization,.

Collection of sperms
 Liquefied ,centrifuged, suspended in culture medium,
and incubated for 30-60 mins at 37⁰ C.
 The most active sperms are located in the surface of
the medium.
 Sperm may be obtained from the testicle, epididymis,
or vas deferens from men whose semen is void of
sperm either due to an obstruction.

In vitro fertilization of oocytes
 Fertilization is started by adding 10,000-
50,000 motile sperms to about 100 μl to 1 ml
culture medium in which the oocytes is being
incubated.
 Intra-cytoplasmic sperm injection (ICSI) is
indicated in cases where semen fluid does
not contain sperm.

Types.
 Intra-uterine Insemination (IUI)
 In- vitro fertilization (IVF)/ Embryo transfer
 Intracytoplasmic sperm injection (ICSI)
 Gamete intra-fallopian transfer (GIFT) &
 Zygote intra-fallopian transfer (ZIFT)

Intra-uterine
Insemination(IUI)
 First line
 Indications
 Hostile cervical mucus
 Anti-sperm or male
fertility problem (low
sperm count or premature
ejaculation)
 Although tubal patency of
female partner must be
assured

In- vitro fertilization (IVF)/
Embryo transfer
 Fertilization occurs
outside the body.
 Indications
 Uterine tube occlusion
 Endometriosis or
cervical mucus
problems,
 where male factors
are main problem

Intracytoplasmic sperm
injection (ICSI)
 The injection of a single
sperm into the cytoplasm
of an egg with a fine glass
needle.
 Useful technique when
sperm quality is poor.
 In azoospermic man sperm
can be obtained surgically
from the epididymis or by
extraction from testis itself.

Intra-cytoplasmic sperm
injection (ICSI)
 An embryologist
isolates a sperm cell,
draws it up into a
microscopic needle and
injects it inside an
oocyte using a high
power microscope.
 Fertilisation check is
performed the next day

injection (ICSI)
 Approximately 18 hours
after sperm injection or
insemination of the
eggs.
 Usually 65% to 75% of
mature eggs will
fertilize after
insemination

injection (ICSI)
 They are cultured in special incubators to
support division and development.
 If the couple has a history of certain genetic
disease and the gene that is causing that
problem is identified, a pre-implantation
genetic diagnosis may be done.

Embryo transfer
 Performed on day 2, 3 or 5
post fertilization.
 One or more embryos
suspended in a drop of
culture medium are drawn
into a transfer catheter, a
long, thin sterile tube with a
syringe on one end.

Embryo transfer
 The physician gently
guides the tip of the
transfer catheter
through the cervix and
places the fluid
containing the embryos
into the uterine cavity

Embryo transfer
 Related to age and embryo quality
 o <35 = 2
 o 35-37 = 2-3
 o 38-40 = 3-4
 o >40 = up to 5
 For patients with 2 or more failed IVF cycles, or a poor
prognosis, can add more based on clinical judgement

Variations of IVF
 Gamete intrafallopian
transfer (GIFT)
 Zygote intrafallopian
transfer (ZIFT).

Gamete intra-fallopian transfer
(GIFT) & Zygote intra-fallopian
transfer (ZIFT)
 Laparoscopic technique that offer little
clinical advantage over invitro fertilization
(IVF)

Infertility and ivf

More Related Content

What's hot

Similar to Infertility and ivf

More from Dr Nilesh Kate

Recently uploaded

Infertility and ivf