Overview of ART.pptx

OVERVIEW OF ASSISTED REPRODUCTIVE TECHNIQUES Dr. B.O. Rosiji Obstetrician & Gynaecologist Hospitals’ Management Board, Ado- Ekiti  Historical perspectives 1890 :Walter Heape of University of Cambridge: embryo transplant in rabbits 1932: Aldous Huxley Bra...

OVERVIEW OF ASSISTED REPRODUCTIVE TECHNIQUES Dr. B.O. Rosiji Obstetrician & Gynaecologist Hospitals’ Management Board, Ado- Ekiti  Historical perspectives 1890 :Walter Heape of University of Cambridge: embryo transplant in rabbits 1932: Aldous Huxley Brave new world 1959:Mc Chang: achieved births in rabbits through IVF 1961:Palmer in France described removal of oocyte by laparoscopy  Historical perspectives... 1973: 1st IVF pregnancy reported by Monash group in Australia 1976 :Ectopic pregnancy reported by Steptoe & Edwards 1978 :The first successful birth of a "test tube baby", Louise Brown 2010: Robert G. Edwards, was awarded the Nobel Prize in Medicine.  Assisted reproductive techniques ART refers to processes including IVF which increase the likelihood of conception in the treatment cycle and usually involves the handling of gametes. Less than 30% of infertile couples will achieve conception by conventional fertility treatment Evaluation of infertile couple Detailed history –previous obstetric/gynae Fertility test/ treatment Infection screen, HBV,HCV,HIV VDRL Seminal fluid analysis Ovarian reserve testing other tests as indicated Comprehensive medical evaluation as needed  SFA Liquefaction: 30mins Volume - At least 2-5 mls Sperm concentration - at least 20 million/mL Motility – at least 50% or more with forward progression Morphology - At least 30% or more normal forms White blood cells - Fewer than 1 million/ml Ovarian reserve assessment Day 2-5 FSH,LH,Prolactin Basal oestradiol level Anti Mullerian hormone Inhibin B Clomiphene challenge test Ovarian volume Antral follicle counts  Steps in IVF treatment Controlled Ovarian Hyperstimulation Oocyte retrieval Fertilisation – insemination/microinjection Embryo transfer  Drugs in COH Medication to suppress the LH surge and ovulation until the developing eggs are ready. Mainly – GnRH-agonist (gonadotropin releasing hormone agonist) such as Lupron ,buserellin – GnRH-antagonist such as Ganirelix or Cetrotide FSH to stimulate development of multiple eggs – Gonal-F, Follistim, Bravelle, Menopur HCG to cause final maturation of the eggs  Protocols Luteal Lupron protocol also called "long Lupron", or agonist "down regulation" Antagonist protocols that involve use of the GnRH antagonist medications Flare and micro-flare protocols also called short protocols are used for patients expected to have a low response to ovarian stimulation  Oocyte retrieval When diameter is 18-20mm in 3 follicles,5000-10,000 IU of hCG is given. Retrieval procedure takes place about 34- 36hrs later Retrieval is done using a transvaginal technique Follicles are aspirated, and the follicular fluid is handed to the IVF laboratory to identify ova The retrieval procedure takes about 20 minutes and is usually done under conscious sedation or general anaesthesia Ovarian follicles  Oocyte retrieval Laparoscopic : used in the 80s especially when GIFT was common, high risk of morbidity Transabdominal :First performed in 1981, the aspirating needle goes through the bladder, which acted as a window Transvaginal : First performed in 1984 and has now become the procedure of choice because of its ease and low morbidity. Oocyte retrieval Fertilisation /Embryo culture The sperm and the egg are incubated together in the culture media for about 18 hours. When indicated , a sperm may be injected directly into an egg using micromanipulation The fertilised egg is then cultured until the egg consists of six to eight cells. Transfer may be done on day 2, 3 or  EMBRYO TRANSFER Considered the critical step in IVF No of embryo transferred depend on several factors : Patients age No of prior failed IVF treatment Quality of embryos Use of thawed embryos Regulation  Success rates This is variable Average 25-30% Depends on several factors maternal age duration of infertility bFSH number of oocytes, All reflecting ovarian function  Other factors affecting success rates Tobacco smoking Body mass index Salpingectomy before IVF treatment increases chances for women with hydrosalpinges Previous pregnancy/live birth Low alcohol/caffeine intake Level of DNA fragmentation Semen quality  Complications Ovarian hyperstimulation syndrome Ectopic pregnancy Heterotropic pregnancy Most recent studies show that the previously suggested long term risk of epithelial ovarian CA, breast CA and premature menopause are unfounded  GIFT Developed in 1984 for women with unexplained infertility. Indicated in religious and ethnic communities in which fertilization outside the body is not acceptable Patient undergoes a controlled ovarian hyperstimulation. The oocytes are retrieved transvaginally under ultrasonographic guidance 3-4 oocytes are placed via laparoscopy into one of the fallopian tubes along with sperms  ZIFT Oocytes are retrieved and fertilized in vitro in the laboratory as in IVF. At 2 cell stage, 3-4 embryos are transferred via laparoscopy into one of the fallopian tubes. Beneficial in women who are thought to have compromised embryo quality due to embryo in vitro culture. Risk of ectopic pregnancy is high  IVF / ET In vitro fertilisation Embryo transfer With the development of enhanced culture media, the success rates for IVF are presently better than those of GIFT and ZIFT Risk of ectopic gestation is less with IVF IVF is less invasive than GIFT and ZIFT  Male factor infertility Couples with male factor infertility are not so amenable to conventional IVF Several procedures have been tried in an attempt to circumvent zona pellucida and perivitelline space 1992 Parlemo described ICSI 2002 Benjamin Bartoov described IMSI Microinjection  MICROMANIPULATION TECHNIQUES Partial Zona Dissection (PZD); mechanical distruption of Zona to grant assess to sperms Subzonal Insemination (SUZI); several sperm cells are delivered to perivitelline space Intracytoplasmic Sperm Injection (ICSI) ;single motile spermatozoon is injected directly into the ooplasm IMSI ; Morphologically selected sperm is directly injected into the ooplasm  IMSI Latest advance in micromanipulative IVF Sperms are examined under high magnification microscopy x 6300 Most “normal” sperms are identified for microinjection Indicated in severe male factor infertility Recurrent implantation failure Recurrent abortion Abn sperms in high magnification Normal sperm cell  Advantages of IMSI Increases pregnancy rates by 50% over ICSI Reduces miscarriage rates by 75% over ICSI Shown to identify viable sperms in men who were considered azospermic under normal magnification Treatment of choice in surgically obtained sperms  OTHER SPERM COLLECTION TECHNIQUES MESA (Micro-epidymal sper aspiration) PESA (Per-cutaneous sperm aspiration) TESA(Testicular sperm aspiration)  Third party ART Production of an offspring through the gametes /uterus of an individual who will not be involved in parenting sperm donation Oocyte donation Embryo donation Gestational surrogate INTENSE SOCIOCULTURAL/RELIGIOUS IMPLICATIONS  Ethical considerations in ART Pregnancy after menopause Same sex couples Single parents Discarding of embryos Unmarried parents Gamete donation Embryo donation Cryopreservation  Challenges in developing countries Cost of consumables Use of expensive delicate equipment Manpower training Poor power supply Lack of legislation Lack of monitoring body Delayed referral Lack of counselling services Sociocultural norms / practices  IVF related services Vitrification Laser Assisted Hatching Sex selection Preimplantation Genetic Diagnosis THANK YOU