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Ivf necessary element in gynaecology
- 2. There are novel concepts in Infertility that we need to know. They will make a difference in your clinical practice
- 3. The inability to create a desired pregnancy that culminates in the birth of a child is likely to create a life crisis for women and their partners. Women seeking fertility treatment look to nurses for care, counsel and health teaching.
- 4. • Primary infertility: The inability to conceive after 1 year of unprotected intercourse for a woman younger than 35, or after 6 months of unprotected intercourse for a woman 35 or older (Speroff & Fritz, 2005). • Secondary infertility: The inability of a woman to conceive who previously was able to do so (Speroff & Fritz, 2005).
- 5. Infertility is more common in older women. However, increased age reduces the efficacy of treatment.
- 6. Infertility affects 15 % of couples, and 50-70 % of male infertility is potentially correctable so it name As: Subfertility …….
- 8. Evaluation of decreasing sperm count Environmental Health Perspectives 108 (10) (Oct. 10, 2000); E. Carlsen et al. British Medical Journal 305 (Sept. 12, 1992).
- 10. Journal of Andrology, Vol. 28, No. 2, March/April 2007
- 11. Journal of Andrology, Vol. 30, No. 5, September/October 2009
- 12. Semen analysis •New reference values by WHO Semen Parameter WHO 1999 WHO 20101 Volume (mL) ≥2.0 1.5 Count (x106/mL) ≥20 15 Total sperm number per ejaculate ≥40 39 Motility (%) ≥50 (a+b) 32 (a+b) Vitality (%) ≥75 58 Morphology (%)2 (14) 4 Leukocytes (x106/mL) <1.0 <1.0 1Lower Limit (5% percentile); Recent fathers Grade a = rapid progressive motility Grade b = slow/sluggish progressive motility 2Strict criteria
- 13. 1,953 semen samples of recent fathers Time to pregnancy (TTP) ≤ 12 mo 5 studies in 7 countries on 3 continents Laboratories with QC only Morphology by strict criterion (Kruger) Progressive and non-progressive motility Lower reference limits (5th centile) 13
- 14. 1. The Open Reproductive Science Journal, 2011, 3, 7-15
- 16. • The overall incidence of infertility has remained relatively unchanged for the past 30 years (Speroff & Fritz, 2005). • In 2002, about 2 percent of women of reproductive age had an infertility-related medical appointment within the previous year, and 10 percent had an infertility-related medical visit at some point in the past (Chandra et al., 2005).
- 17. Approximately half of all women who receive fertility care achieve conception leading to a live birth (Speroff & Fritz, 2005).
- 18. Types of ART cycles: United States, 2004 (Speroff & Fritz, 2005)
- 19. Previous
- 20. Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, et al. (2012) National, Regional, and Global Trends in Infertility Prevalence Since 1990: A Systematic Analysis of 277 Health Surveys. PLoS Med 9(12): e1001356. doi:10.1371/journal.pmed.1001356 http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001356 Present: Prevalence of primary infertility among women who seek a child, in 2010.
- 21. Present: Prevalence of secondary infertility among women who have had a live birth and seek another, in 2010. Mascarenhas MN, Flaxman SR, Boerma T, Vanderpoel S, et al. (2012) National, Regional, and Global Trends in Infertility Prevalence Since 1990: A Systematic Analysis of 277 Health Surveys. PLoS Med 9(12): e1001356. doi:10.1371/journal.pmed.1001356 http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001356
- 22. Medication: when and how to use antioxidants 0 0.5 1 1.5 2 2.5 Fertile Infertile Seminal Reactive Oxygen Species (ROS) (Log ROS + 1; cpm) Pasqualotto et al., Fertil Steril 2000
- 23. Success rate:
- 24. Reasons : Increase use of contraception
- 25. Semen analysis •New reference values by WHO Semen Parameter WHO 1999 WHO 20101 Volume (mL) ≥2.0 1.5 Count (x106/mL) ≥20 15 Total sperm number per ejaculate ≥40 39 Motility (%) ≥50 (a+b) 32 (a+b) Vitality (%) ≥75 58 Morphology (%)2 (14) 4 Leukocytes (x106/mL) <1.0 <1.0 1Lower Limit (5% percentile); Recent fathers Grade a = rapid progressive motility Grade b = slow/sluggish progressive motility 2Strict criteria
- 26. 1,953 semen samples of recent fathers Time to pregnancy (TTP) ≤ 12 mo 5 studies in 7 countries on 3 continents Laboratories with QC only Morphology by strict criterion (Kruger) Progressive and non-progressive motility Lower reference limits (5th centile)
- 27. In vitro fertilisation
- 28. In vitro fertilisation In variable fertilisation (100% sure)
- 29. Previous: tubal factor only Fallopian Tube Damage/Tubal Factor Bilateral blocked Fallopian tubes Failed reversal of Tubectomy The only options for treating significant tubal damage are surgical repair or bypassing the tubes with IVF. This decision must be carefully individualized in each situation.
- 30. Present: Male Factor Infertility Failed reversal of Vasectomy/ Tubectomy Obstructive azoospermia Endometriosis Severe endometriosis Age Related Infertility Premature Menopause Anovulation Unexplained Infertility Preimplantation Genetic Testing (PGT
- 31. Previous: myths – Myth: IVF is only the last option Myth: IVF is only for affluent people Myth: IVF is limited to a younger population only Myth: IVF is successful in all cases Myth: IVF requires admission in the hospital Myth: IVF always result in multiple pregnancies like twins or triplets Myth: IVF babies have a significantly high risk of birth defects and malformations Myth: IVF is covered by insurance Myth: IVF is dangerous
- 32. Present : reality- Who Does it Help? In-Vitro Fertilization and the Hermeneutic of the Gift Woman’s uncensored journey Maternal Age and Blastocyst Development Frozen Blastocyst Cycles The Future
- 33. Present : reality- The Future
- 34. DARR LACK OF CONFIDENCE LACK OF SENIORS SUPPORT LACK OF KNOWLEDGE FROM WHERE TO LEARN HOW TO ESTABLISH LAB etc….. IVF Without Surgery - Transvaginal Oocyte Retrieval Success rate !!!
- 35. Previous & Present: -Ease of getting equipment & loans -support of companies -disposables& media -hormones( refine technology) -ovum pick up -embryo transfer( role of USG) -endocrinology & lab support -availability of embryologyst - knowledge & skill - ICSI ,IMSCI, PICSI,PGS, PGD,ERRAY , LAH, STEMCELL etc…..
- 36. Assisted reproductive technology INTRACYTOPLASMIC SPERM INJECTION (ICSI) GAMETE INTRAFALLOPIAN TRANSFER (GIFT) ZYGOTE INTRAFALLOPIAN TRANSFER (ZIFT)
- 37. By companies By doctors By laboratories
- 38. Previous: Clomiphene citrate Present: Various options GnRH Agonists GnRH Antagonists Gonadotropins hCG Progesterone Medrol Doxycycline
- 39. Previous: None reported Present: Ovarian Hyperstimulation Syndrome (OHSS) Ovarian cancer Uterine cancer Cervical Cancer Breast cancer Ectopic pregnancy Heterotopic pregnancy Miscarriage
- 40. Fast conception Early identification of factor Demand & supply Dhiraj & dhakka Multiple pregnancy LSCS Both party happiness Remote centre franchise for drs
- 41. Previous: Not aware Present : Many physician refer patient to IVF clinic
- 42. ?????
- 43. Past tense: trial & error fertilisation Present tense: in vitro & in variable fertilisation
- 44. 1. Nowadays, the use of surgically-retrieved sperm and ICSI has become an established procedure for couples wishing to obtain a biological offspring in whom the male Subfertility. 2. So far, the post-natal outcomes of babies born from such fathers are reassuring.
- 45. Understand the reproductive potential of couple undergoing IVF Success of ICSI (Very sucessfull data) Male Factors Infertility IVF ~40% live birth rates Female Factors Infertility IVF Higher results than other infertility causes ~25% live birth rates
- 47. Antioxidants helpful to decrease oxidative stress. Interventions impact on semen quality 60 days later. WHO lowered semen analysis reference values. IVF is beneficial for patient subgroups. IVF and reproductive potential is dependent on the type of infertility 47
Editor's Notes
- Analyses of sperm count data suggest a global downward trend but the results are inconclusive. An increase in male reproductive disorders like cryptorchidism and testicular cancer raise the question of common risk factors. Data on testicular cancer trends are usually based on population-based cancer registries with good validity. The corresponding data from fertility studies need careful consideration in terms of methods and results.Fisch and co-workers determined whether geographic variations in sperm count might bias the conclusions drawn from studies of semen quality. Briefly, of the 61 studies in the meta-analysis of Carlsen et al. [1] only 20 included more than 100 individuals. A reanalysis of these 20 studies revealed that the majority of studies published before 1970 were from USA, mainly New York. These studies represented locations with the highest sperm counts. In contrast, after 1970, most of the studies were from locations not included earlier. Selection bias due to geographical and ethnic variations could account for the observed decline in sperm quality [8]. However, when the subgroup of studies from the USA (28 studies, including data on 8.329 men) was analyzed separately, a similar trend of decreasing mean sperm values was observed [1]. On the other hand, Lipshultz argued that when all the larger studies containing only New York data are excluded from the meta-analysis, a second linear regression analysis detects no decline in sperm density [9].The sperm count issue has been extensively investigated since 1992 and the decrease is supported by additional studies. For example, it was reported that sperm counts of 1351 fertile men (semen donors) in Paris decreased by 2.1 percent per year from 89 × 106/ml in 1973 to 60× 106/ml in 1992 (p < 0.001) [10]. Sperm motility also decreased in these individuals. The mean seminal volume was 3.8 ml and did not change during the period from 1973 to 1992. Irvine et al. also examined sperm quality in 571 semen donors in Scotland by birth cohort groups [11]. They reported a significant decrease in median sperm concentration, total number of sperm in the ejaculate and total number of motile sperm in donors born between 1970 and 1974 compared to men before 1959.On the other hand, several studies confirm that in some locations sperm counts have not decreased over the past 20 to 25 years. More importantly, the results clearly show a remarkable variability in sperm counts at different geographical locations. The mean sperm counts in 302 men in the Toulouse area were unchanged over the period from 1977 to 1992 [12] and their mean sperm count (83 × 106 ml) was significantly higher than observed in the Paris study [10]. Furthermore, it was reported that the highest sperm counts recorded in Finland were found in men from rural areas accompanied by a low incidence of testicular cancer [13]. These findings suggest that urban lifestyle or environmental factors might be an important etiological factor of testicular malfunction and disease.Fisch et al. [14] conducted a study comprising 1,283 men who banked sperm before vasectomy in three different sperm banks in the United States from 1970-1994. A slight but significant increase in mean sperm concentration from 77 × 106 ml to 89 × 106 ml over the past 25-year period was found. Furthermore, marked differences in semen characteristics between the New York, Minnesota, and California sperm banks were found. Sperm concentration and motility was highest in New York and lowest in California.It was argued that the data set analyzed by Carlsen et al. [1] was not equally distributed between the decades: 79% of the publications and 88% of the volunteers of all studies were clustered between 1970 and 1990. If joint-analyses were conducted with studies from this period only, an increase in sperm concentrations would become evident. Thus, only 21% of the studies and 12% of the volunteers analyzed before 1970 have caused the regression to have a statistically negative slope [15,16].Looking at sperm count studies which have been published since 1992, it becomes evident that over the past 20 years, sperm quality has decreased in some but not all locations. The results also show that sperm counts can vary widely between and within countries. These major geographical differences suggest that the results of the former meta-analyses of sperm count may be biased by geographical confounding.
- Interactive regression model for mean sperm density by year and geographic region, after controlling for proven fertility, abstinence time, age, specimen collection method, method of counting sperm, whether the study was included by Carlsen et al. (1), and interaction of region and study year.
- Oligospermia, also oligozoospermia, refers to semen with a low concentration of sperm and is a common finding in male infertility. Often semen with a decreased sperm concentration may also show significant abnormalities in sperm morphology and motility (technically "oligoasthenoteratozoospermia"). There has been interest in replacing the descriptive terms used in semen analysis with more quantitative information.[2]
- The World Health Organization (WHO) has established new reference values for semen characteristics in its 5th edition manual which are lower than those previously reported. Several questions arise after a careful examination of the proposed new values, especially regarding the implications of these references for diagnosis and treatment of male infertility. Despite the notable advance of using controlled studies involving couples whose time to pregnancy was less than 12 months to generate the new limits, reference studies are limited with regard to the population analyzed and the methods used for semen evaluation. As such, it seems unreasonable to assume that reference values represent global semen characteristics of fertile men as proposed in the 5th edition WHO manual. Caution should be exercised to not overinterpret the new reference values as they may fail to accurately discriminate populations of fertile and infertile men. Properly performed semen analyses coupled with an adequate examination of the man can give valuable information related to the organs producing “semen”, a highly complex fluid, and thus help in better understanding of the physiology of the reproductive organs and the causes of their dysfunctions. The present commentary discusses concerns related to the publication of the new reference values for semen parameters such as the impact on patient referral, diagnosis, treatment of recognized conditions such as varicocele and indications of assisted reproductive modalities. We conclude that more debate is needed before the adoption of the proposed WHO current reference values by andrology laboratories around the world. For those considering to adopt them, a better approach would be the presentation of reference values by percentiles rather than solely the lower cutoff limits. The time has come for technological developments that bring robust and costeffective clinically useful sperm function tests to replace, at least partially, the shortcomings of routine semen analysis
- Most of the infertile patients that we see in our clinical practice are at risk of excessive Oxidative Stress. Reactive oxygen species are products of aerobic metabolism. At certain levels they are not detrimental, but several conditions induce an overproduction of ROS, causing oxidative stress. Oxidative stress, that can be measured either in the seminal plasma or directly in the sperm by different methods, are higher in infertile men than fertile ones. Regardless of its cause, the end product of OS is the oxidation of sperm structures that become dysfunctional. The impairment of sperm function caused by OS may be either the only factor causing infertility or a contributor to a recognized disease that cause infertility. Options to minimize OS include: i) the treatment of the underlying pathology, if possible, ii) the removal of risk factors, which is not always feasible, or iii) by the administration of antioxidant supplementation.
- We are just beginning to understand the implications of blastocyst transfer for both practitioners and patients. ,We believe infertility treatment centers will soon be able to reliably grow blastocysts and accurately assess which embryos are destined to implant and develop into an ongoing pregnancy. When that happens, the transfer of a single blastocyst will become the norm. And today's risk of high-order multiples will become a memory. The future holds much hope, much promise, and considerably fewer risks.
- We are just beginning to understand the implications of blastocyst transfer for both practitioners and patients. ,We believe infertility treatment centers will soon be able to reliably grow blastocysts and accurately assess which embryos are destined to implant and develop into an ongoing pregnancy. When that happens, the transfer of a single blastocyst will become the norm. And today's risk of high-order multiples will become a memory. The future holds much hope, much promise, and considerably fewer risks.