This slide is prepared by medical student for educational purpose. Please comment if anything to add on this slide.

1. In Vitro Fertilization
Dr. Jeetendra Bhandari

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. 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

11. 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.

12. 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

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

14. Intrauterine Insemination

15. Introduction
• Procedure to bypass endocervical canal which is abnormal
• Place increased concentration of motile sperm as close to fallopian
tube
• May be either
• Artificial insemination husband
• Artificial insemination donor
• Husband’s semen commonly used

16. Indication
• Hostile cervical mucus
• Cervical stenosis
• Oligospermia or asthenospermia
• Immune factor(male and female)
• Male factor-impotency or anatomical defect but normal ejaculation
can be obtained
• Unexplained infertility

17. Technique
• Methods to extract sperm from seminal plasma
• Washing
• Swim up
• Density gradient centrifugation
• Swim method-allow most motile sperm to swim up into supernatant
• Compared to washing, swim method has no dead sperm and cellular
debris
• About 0.3 ml washed or concentrated sperm injected through flexible
polyethylene catheter within uterine cavity around time of ovulation

18. • Density gradient centrifugation recovers most higly motile as well as
morphogically normal sperm
• Processed motile sperm count for insemination should be at least 1
million
• Best result if motile sperm >10 million
• Normal sperm survive in female reproductive tract can fertilize at
least 3 days
• Procedure can be repeated 2-3 times over period 2-3 days
• To increase sperm mortility, pentoxyphylline(phosphodiesterase
inhibitor) can be used

19. Timing of IUI
• Not so vital; sperm can survive in cervical canal for 1-2 days
• Controlled ovarian hyperstimulation is required

20. • Cumulative conception rate after 12 insemination cycle is 75-80%
• Best result obtained in treatment of cervical factor and unexplained
infertility and in stimulated cycle
• IUI with superovulation gives higher result

21. Artificial Insemination Donor
• Semen of donor is used
• Indication
• Untreatable azoospermia, astenospermia
• Genetic disease
• Rh-negative donor insemination- for women with Rh-sensitization
• Donor is healthy and of same ethnic group as husband
• Donor serologically and bacteriologically free from venereal disease
• Recipient and donor must be matched for blood group and Rh typing

22. • Fresh or frozen semen is used
• Sperm used when it is kept sequestered for at least 180 days
• Legal, psychological and religious aspect should be counseled before
its application

23. Result of technique
• Total of 3-6 cycle may have to be utilized to get success
• Success rate 50-60%

24. 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.

25. Thank you!!