Assisted Reproduction PDF

Assisted reproduction Dr Alaa yousif mahmood obstetric and gynecology department MRCOG (LONDON)/DOG/M.B.ch.B  Theoretical skills Ø Have good knowledge of the indications and treatment options for assisted reproductive techniques. Ø Be aware of the risks associated with ART....

Assisted reproduction Dr Alaa yousif mahmood obstetric and gynecology department MRCOG (LONDON)/DOG/M.B.ch.B  Theoretical skills Ø Have good knowledge of the indications and treatment options for assisted reproductive techniques. Ø Be aware of the risks associated with ART. Ø Have a brief knowledge of the laboratory procedures. Ø Appreciate the emotional, physical and financial stress involved and Ø be aware of the social, ethical and legal implications associated with ART. Ø Have a brief knowledge of the HFEA and practice code. (Human Fertilisation and Embryo Authority)  Intrauterine insemination Intrauterine insemination (IUI) is performed by introducing a small sample of prepared sperm into the uterine cavity with a fine uterine catheter. The most common reasons for IUI are 1- low sperm count or decreased spermmobility. 2-Unexplained infertility 3- hostile cervical condition, including cervical mucos problems 4-Ejaculation dysfunction IUI is not recommended for the following patients: Women who have severe disease of the fallopian tubes Women with a history of pelvic infections  Intrauterine insemination The success rate of this procedure ranges between 10% and 20% per treatment cycle. This process may be preceded by several days of mild stimulation with subcutaneous injections daily of exogenous FSH, with the aim of stimulating the ovaries to produce 2–3 mature follicles (this is termed stimulated IUI). Follicular tracking with ultrasound is essential to avoid over- or under stimulation. Triggering of ovulation (and therefore the timing of the insemination) is achieved with a subcutaneous injection of human chorionic gonadotrophin (hCG). Drugs used for ovulation induction in anovulatory cases as PCOS. By Bijar Raziki  In-vitro fertilization IVF was originally designed for couples with tubal factor subfertility IVF is now used for almost all cases of subfertility including tubal disease, endometriosis,failed IUI or where donor eggs are needed. Originally, IVF was performed in the natural menstrual cycle, but the use of gonadotrophin -controlled ovarian stimulation made IVF a much more efficient process. ART in the UK is regulated by the Human Fertilisation and Embryo Authority (HFEA),  IVF TREATMENT CYCLE Pituitary down-regulation In the most commonly used IVF cycle the pituitary gland is down-regulated to prevent endogenous LH surges and premature ovulation. A gonadotrophin-releasing hormone (GnRH) agonist is used to block the FSH and LH release from the pituitary. Newer approaches involving the use of GnRH antagonists can shorten treatment time and reduce the incidence of ovarian Hyper stimulation syndrome.  Controlled ovarian stimulation This is achieved using daily subcutaneous doses of gonadotrophin medications, which cause multiple follicle recruitment. Close monitoring with TVUSS predicts the number of follicles and the timing of the egg collection. Ideally, around 15 follicles are recruited. Blood levels may be taken to measure oestradiol levels, and are used by some to measure ovarian response to stimulation. Ultrasound measurement of endometrial thickness is also performed.  Inhibition of premature ovulation Feedback from rising oestradiol associated with follicular development should lead to an LH surge from the pituitary, resulting in final oocyte maturation and ovulation. In IVF this is blocked to allow scheduling of egg collection. This is traditionally done by the administration of GnRH agonists, or with a newer shorter GnRH antagonist protocol. hCG trigger hCG is used as a surrogate for the endogenous LH surge. It causes final maturation of the egg and allows scheduling of the egg collection procedure.  Gonadotropin CF5H) GnRH④ o r - 0 NV5 hCG 36-37h abdominal PG17 → -  Egg collection This procedure is usually performed about 37 hours post hCG trigger. Under anaesthesia a needle is inserted into the ovaries under TVUSS control, and follicular fluid is aspirated from each follicle that contains an oocyte, which is collected by the embryologist into the laboratory.  Fertilization Fertilization is performed using prepared sperm. Conventional IVF fertilization involves the insemination of around 100,000 sperm in a petri-dish with an egg. In cases of poor sperm parameters or in cases of previous poor fertilization, individual sperm can be isolated and directly injected into the cytoplasm of the oocyte (intra cytoplasmic sperm injection, ICSI) Fertilization is checked the next morning and is usually in the region of 60% for IVF and 70% for ICSI.  holding t o o l polar body 1. I OVUM i n m e o s i s 2 ✓ 1. needle t o do I C I Ovum is rotated until polar body is at 12 or 6 o’clock and the needle is inserted at 3 o’clock (opposite to the holding tool).  Embryo culture Embryos are incubated under strict conditions of temperature, pH, humidity and oxygen concentration. They may be transferred back into the uterus after 2, 3 or 5 days of development. Embryos reaching the blastocyst stage on day 5 of development usually exhibit the best chance of implantation. A variety of different protocols are available for embryo selection, including a morphological and a morpho-kinetic assessment.  Embryo transfer Embryos are transferred into the uterus using a soft plastic catheter. The choice of how many embryos to transfer is the decision of the couple following expert medical and embryological advice; Embryo transfer is usually performed under Trans abdominal ultrasound control to ensure correct placement of the embryos. In the UK and Europe there are recommendations regarding the transfer of single embryos to reduce the incidence of multiple If < 3 7 year pregnancies and their associated risks. 2- i f > 3 7  Luteal phase support The use of gonadotrophin agonists or antagonists to prevent a premature LH surge will lead to a reduction in the ability of the corpus luteum to produce progesterone. Patients are therefore supplemented with progesterone following the egg collection. There is no consensus on the ideal dose, route or duration of progesterone supplementation. A pregnancy test is performed around 14 days after embryo transfer.  Embryo cryopreservation Spare embryos of good quality may be cryopreserved for future use..  ART success rates IVF success rates are exquisitely sensitive to female age. In young patients under the age of 35 success rates can be as high as 40–45% from a single cycle, while in women over the age of 40 they will fall below 15%. Undergoing IVF does not preclude the patient from the normal complications of pregnancy, such as miscarriage or ectopic pregnancies.  Risk of IVF The most significant risk of IVF treatment is ovarian Hyper stimulation syndrome (OHSS), 0 occurring in 1–3% of cases. Patients with severe OHSS present with ascites, enlarged multifollicular ovaries, pulmonary oedema and coagulopathy. These patients need to be admitted to hospital and managed under strict protocols under the care of specialist teams. The use of low-dose stimulation, ultrasound monitoring, GnRH antagonist protocols, GnRH agonist triggers and amore liberal freezing policy have significantly reduced the incidence of this very serious condition.  Surgical sperm retrieval Where the sperm quality or quantity is low but sperm are present, ICSI is required to help achieve a one Introcu topoumicspenInjection oneoperm egg pregnancy. However, in the absence of naturally ejaculated sperm (termed azoospermia – which may relate to blockage of the vas deferens or testicular problems), patients may undergo surgical sperm retrieval (SSR). SSR can be performed under sedation or o general anaesthesia. A fine needle is inserted into the epididymis or the testicular tissue to obtain sperm or testicular tissue with sperm, respectively. The retrieved sperm can then be cryopreserved or injected into the oocyte as part of a fresh IVF/ICSI cycle.  Preimplantation genetic diagnosis Couples who carry a genetic disease (but who are fertile) may choose to use IVF and preimplantation genetic diagnosis (PGD) to avoid an affected pregnancy. These patients may previously have had affected children or terminations for an affected fetus. IVF will create multiple embryos. These embryos can then be genetically tested for the relevant disease, by the removal of several cells at the blastocyst stage that are tested and taken to reflect the genotype of the remaining embryo. Only embryos free of the disease are transferred into the uterus. PGD has now been used worldwide for most monogenic diseases, as well as for translocations. Also to select the sex of the embryo (e.g a couple who are normal but would want a girl or a boy can do IVF to select the sex). Preimplantation genetic diagnosis  Fertility preservation Patients may face treatments such as chemotherapy, radiotherapy or surgery that could significantly damage their gonads and reduce their reproductive potential. For many years men have been able to‘bank’ sperm ahead of these treatments. Couples can now undergo rapid IVF procedures and cryopreserve embryos for use later on when health is regained.  Donor gametes Donor sperm can be used to treat patients where the male partner is azoo spermic or in the case of single women or female same sex couples. Both IUI and IVF treatments are possible. Donor eggs may be used if the female has undergone early menopause or if IVF treatments have been unsuccessful and associated with a reduced ovarian reserve and low egg number and quality. Gamete donation requires careful and thorough counselling and most countries have legislation to regulate its use.  collection t u b e 1 ' attached t o suction pump ① ④ ② ↳ Ovum pickup system ⑤ Embryo transfer catheter IUI catheter IVF steps: 1. Controlled Ovarian Stimulation (GnRH ⊕/⊖, FSH, hCG). Close monitoring with TVUS (number/size of follicles & endometrial thickness) and blood estradiol level. We need at least 4, ideally 15 follicles of 18 mm. 2. Oocyte Retrieval: under TVUS. 3. Oocyte Fertilization: (insemination or ICSI) 4. Embryo Culture: under strict conditions, check fertilization at day 1. 5. Embryo Transfer: at day 5 from fertilisation which is a blastocyst and best time to implant in the uterus, it will undergo lysis at day 7 if you don’t transfer. 6. Luteal phase support. Oocyte retrieval (ovum pick up): It’s like a minor surgery, called follicular aspiration. Under TVUS, a needle will be inserted with a guide wire through vaginal wall in to the ovary (should use condom for US and no detergent so that egg will be healthy. Should know anatomy to avoid vein injuries. Aspirate each follicle, and check under microscope if ovum is retrieved or need to wash follicle and aspirate again. With this procedure also the semen from the husband should be prepared. – Should give the husband a sterile cupped container – Should be abstinence from ejaculation for 5 days – Should not use any detergent or lubricant for ejaculation Fertilization: Either by insemination (100000 sperms put in a container with oocyte and waiting for spontaneous fertilization) or ICSI (in which we cat the tail of motile sperm and inject it via a needle to the oocyte, this is to prevent tail movement from damaging ovum DNA. You need to inject it at 90 degree angle to polar body. we can only do ICSI if there is a polar body which means that the ovum has finished meiosis 1) Drugs used in IVF protocols: OCPs: to synchronize the follicles, so that many will grow simultaneously. GnRH ⊕/⊖: to down-regulate pituitary so that the ovary would be under our control and not rupture spontaneously (prevents LH surge). Antagonist has a shorter course and less risk of OHSS because it would work immediate unlike agonist which need sometime before IT it actually inhibit pituitary thus needing a longer course. Gonadotropins (FSH): daily injection for 8-10 days. from ○ ○ Recombinant FSH (Follistim 200 IU, Gonal-F 75 IU) date outition hMG: extracted FSH from urine of menopausal women (Menopur 75 IU) hCG trigger (ovidrel, novarel 10 000 IU): for final maturation of follicle and timing of oocyte retrieval after about 36-37 hours. You may use GnRH⊕ as trigger if you have used GnRH⊖ to prevent LH surge and estradiol level is high. Estrogen: this is the only one given if you would like to transfer preserved embryos because you don’t need ovarian stimulation here, you just need to prepare endometrium by estrogen and then support luteal phase by progesterone after transference of embryo. Progesterone: for luteal phase support because corpus luteum is inhibited by GnRH ⊕/⊖ Ovarian hyperstimulation syndrome (OHSS): a potentially fatal complication of excess stimulation of ovaries by gonadotropins either in IVF or part of ovulation induction for IUI or PCOS treatment that leads to activation of ovarian RAAS & VEGF. Presents with → N&V, abdominal distension and discomfort, breathlessness, ascites, pleuralb& pericardial effusions, hemoconcentration, VTE, ARDS. (All of them would worsen if pregnancy occurs due to hCG further stimulating the ovaries). Risk of OHSS has been reduced due to: – Low dose stimulation (of FSH) – – o Using GnRH antagonists instead of agonists Frequent follow up by US and estradiol levels – Cryopreservation of embryos for future uses which doesn’t require another IVF cycle. https://youtu.be/v8z0WnV-Mcg?si=1IdFK5la-GAYc_AT