Assisted Reproduction Technology

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Assisted Reproduction Technology

• Presented by

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Introduction

• Infertility is a very common condition affecting
  approximately 13-14 of couples in the
  reproductive age group.
• Although this prevalence has remained stable
  over the last few years, the demand for
  infertility services has increased substantially.
  
• This increase is due primarily to the Baby Boom
  generation entering into the reproductive age
  group at a time of highly publicized
  technological advances.

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Topics of Discussion

• Definition of Infertility ART
• Common causes of infertility
• Who is eligible for ART
• Methodology of ovulation induction
• Improving SPA
• Other techniques
• Counseling couple

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Topics of Discussion Contd

• Failure rate
• Cost effectiveness

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Definition of Infertility ART

• Infertility is defined classically as the
  inability to conceive after 1 year of unprotected
  intercourse. This definition is based on the
  cumulative probability of pregnancy

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Definition of Infertility ART Contd
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Definition of Infertility ART Contd

• ART refers to all techniques involving direct
  retrieval of oocytes from the ovary
• ART procedures include IVF, GIFT, ZIFT, and ICSI.
• The simplest ART procedure, IVF has been around
  for over 20 years and is perhaps the most
  commonly recognized ART of all procedures.

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Common causes of infertility
Causes of Infertility
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Common causes of infertility Contd

• Female factors
• Cervical factor
• Ovulatory factor (PCOs)
• Uterine factor (endometriosis)
• Pelvic factor

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Common causes of infertility Contd

• Polycystic Ovarian Syndrome (PCOS) Also known as
  Stein-Leventhal syndrome
• Also known as hyperandrogenic chronic anovulation
  is a benign disorder that commonly results in
  infertility.
• PCOS is characterized by irregular ovulation and
  menses, obesity, insulin resistance, acne, and
  hirsutism.
• Most women with PCOS also have ovaries filled
  with multiple benign cysts.

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Common causes of infertility (PCOS) Contd

• How does PCOS contribute to Infertility?
• Impaired fertility is a prominent feature of
  PCOS.
• This is believed to result from elevated insulin
  levels that stimulate excess androgen production
  by the ovaries.
• The androgens cause premature follicular wasting
  which causes inconsistent or absent ovulation,
  which is associated with infertility.

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Common causes of infertility (PCOS) Contd
Diagnosis

• Symptoms
• Irregular or absent periods
• Lack of ovulation
• Weight gain
• Hirsutism (excessive hair growth)
• Insulin resistance
• Acne
• Male-pattern balding
• Multiple small ovarian cysts-these may be seen by
  an ultrasound examination
• Ancthosis nigrans (darkening of the skin at the
  nape of the neck and under the arms and breasts).

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Common causes of infertility (PCOS) Contd
Diagnosis

• Blood Work/Hormonal Testing
• Laboratory testing is important for diagnosis but
  it is crucial to look at multiple values
  collectively.

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Common causes of infertility (PCOS) Contd
Diagnosis

• Ultrasound
• Ultrasound of the pelvis is typically performed
  when the clinician suspects PCOS.
• If gt10 cysts are found in either ovary that are
  less than 10mm, this meets the ultrasound
  criteria for PCOS. Furthermore, polycystic
  ovaries are typically 1.5 to 3 times the normal
  size.
• Just the presence of polycystic ovaries, without
  symptoms and/or consistent blood work, does not
  confirm a diagnosis of PCOS.

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Common causes of infertility (PCOS) Contd

• Treatment
• Weight Loss, Progestins, Oral Contraceptives,
  Anti-Androgens, GnRH agonists, Fertility drugs,
  Surgical therapy
• a) Ovarian wedge resection
• b) Laparoscopic ovarian drilling

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Common causes of infertility Contd

• Endometriosis
• Endometriosis can be defined as a nonmalignant
  disorder in which functioning endometrial tissue
  is present outside the uterus.
• The incidence of this disease ranges from 10-15
  in women between the ages of 25 and 44 who are
  actively menstruating, but it also occurs in
  teenagers.
• It is estimated that 25-50 of infertile women
  have this disease.

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Common causes of infertility (Endometriosis)
Contd

• The incidence is higher in first degree relatives
  of women with endometriosis, which suggests that
  heredity may play a role.
• In addition, there is also a higher prevalence of
  the disease in women who delay childbearing or
  who are of Asian descent.

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Common causes of infertility (Endometriosis)
Contd

• Causes and Symptoms
• The cause of endometriosis is unknown, however
  there are several theories.
• The first theory is known as retrograde
  menstruation, or the movement of sloughed
  endometrial tissue back through the fallopian
  tubes and into the abdominal cavity. This tissue
  can then attach itself to various internal organs
  or tissues outside of the uterus.
• Immune system dysfunction. It is believed that
  certain women may develop endometriosis due to
  deficiencies in their immune system.

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Common causes of infertility (Endometriosis)
Contd

• In women without endometriosis, the immune system
  destroys any ectopic implants that may develop.
  However, in women with endometriosis, there is an
  altered immune response and the body is unable to
  destroy the growth of the implants.
• Furthermore, some scientists believe that
  endometriosis is an autoimmune disorder. This
  means that the body makes antibodies to
  endometrial cells. These antibodies may destroy
  the healthy endometrium found in the uterus, but
  are ineffective in destroying ectopic implants.

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Common causes of infertility (Endometriosis)
Contd

• Symptoms
• Pelvic pain and cramping before and during
  periods
• Pain during intercourse
• Inability to conceive
• Fatigue
• Painful urination during periods
• Gastrointestinal symptoms such as diarrhea,
  constipation, and nausea

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Common causes of infertility (Endometriosis)
Contd

• There are other medical conditions that have
  similar symptoms and should be considered prior
  to making a diagnosis of endometriosis.
  Conditions that may cause generalized pelvic pain
  include
• Pelvic inflammatory disease (PID)
• Pelvic adhesions
• Neoplasms (cancers), both benign or malignant
• Ovarian torsion
• Sexual or physical abuse
• Other causes that are not gynecologic in nature

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Common causes of infertility (Endometriosis)
Contd

• How does endometriosis contribute to infertility?
  
• The cause of infertility is believed to result
  from the scarring and adhesions that form in the
  reproductive tract as a result of inflammation.
• Scar tissue and adhesions may reduce fertility by
  either obstructing or distorting the shape of the
  fallopian tubes, which in turn impedes the
  passage of sperm to the egg.

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Common causes of infertility (Endometriosis)
Contd

• In the event that sperm do reach the egg, they
  may encounter a hostile environment unfavorable
  to fertilization.
• Finally, scarring from endometriosis may obstruct
  the fallopian tubes so that if an egg is
  fertilized, it may be unable to travel to the
  uterus for implantation.

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Common causes of infertility (Endometriosis)
Contd

• Diagnosis
• One of two techniques may be used to confirm the
  diagnosis of endometriosis. Both procedures
  involve visualization of the pelvic cavity in
  order to confirm the presence or absence of
  ectopic implants.
• laparoscopy
• laparotomy
• If there are any suspected ectopic implants, they
  are biopsied in order to determine the presence
  of endometrial cells.

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Who is eligible for ART

• Women with tubal diseases
• Unexplained infertility
• Endometriosis
• Immunologic causes for infertility
• Women with premature ovarian failure
• Individuals with male factor infertility (e.g.,
  abnormalities in sperm production, function or
  transport or prior vasectomy)

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Methodology of ovulation induction Contd

• Basically, this term refers to the use of
  medications to stimulate your body to produce one
  or more eggs.
• Ovulation induction can be as simple as taking a
  daily pill or more complicated, like injecting
  fertility medications and seeing your specialist
  daily for necessary monitoring. The simplest form
  of ovulation induction involves taking
  clomiphene.

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Methodology of ovulation induction Contd

• More potent medications, known as the
  gonadotropins, are available for more intensive
  ovulation induction.
• Gonadotropins are injectable medications that are
  made up of a combination of follicle stimulating
  hormone (FSH) and luteinizing hormone (LH) or
  just FSH alone.
• These hormones can be very helpful in getting a
  woman to produce and release her eggs.

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Methodology of ovulation induction

• The success of ovulation induction in achieving a
  pregnancy is highly variable. It depends on the
  diagnosis, age, the medication being used, and
  numerous other factors.

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Improving SPA

• Sperm penetration assay (SPA) is a multi-step
  laboratory test that offers a biological
  assessment of human sperm fertilizing ability.

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Other techniques

• ZIFT
• GIFT
• TEST
• POST
• ICSI
• TESE
• MESA

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Other techniques Contd

• ZIFT
• Zygote Intrafallopian Transfer. ZIFT may be
  recommended if the husband has severe male
  fertility factor or if there has been difficulty
  confirming fertilization with past procedures.
  ZIFT has the advantages of allowing fertilization
  to be confirmed and it has demonstrated higher
  success rates than IVF when used for the
  appropriate indications.
• One disadvantage with ZIFT is that the transfer
  of the zygote must be performed through a
  laparoscope.

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Other techniques Contd

• GIFT
• Gamete intrafallopian transfer was developing in
  1984 as a variation of in vitro fertilization
  (IVF).
• Gift is recommended when
• unexplained infertility
• infertility due to immunological factors
• endometriosis
• selected cases of male infertility
• Tubal infertility
• A requirement for the procedure is that the
  female partner having at least one open (patent)
  fallopian tube.

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Other techniques Contd

• TEST
• Tubal Embryo Transfer the placing of cleaving
  embryos into the fallopian tube.
• POST
• Peritoneal Oocyte and Sperm Transfer the
  placement of oocytes and sperm into the pelvic
  cavity

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Other techniques Contd

• ICSI
• Intracytoplasmic sperm injection, or ICSI, was
  developed to treat couples who previously had a
  very poor probability of achieving fertilization
  due to the male partner's extremely low numbers
  of viable sperm.
• This treatment, when combined with in vitro
  fertilization, allows these couples a more
  favorable probability of achieving conception.

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Other techniques Contd

• TESE
• Testicular Sperm Extraction
• MESA
• Microsurgical Epididymal Sperm Aspiration

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Counseling couple

• The use of skills that enable a client to
  recognize and identify his (sic) own problems,
  and the ability to help client find his own
  solution or resolution.
• The Human Fertilization and Embryology Authority
  (HFEA) state in their code of practice that three
  sorts of counseling must be available at licensed
  treatment center. These are
• Support counseling
• Implications counseling
• Therapeutic counseling

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Success rates "take home baby rate"

• One of the first questions that most people ask
  is "what is the chance for success?" The best
  estimate is that the birth of a live baby occurs
  in approximately 15-25 of women in whom embryos
  are transferred into the uterus.
• The 1998 nationwide live birth rate as reported
  in the IVF-ET Registry, was 24.9.
• The corresponding rate for 1989 was 14.

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Success rates Contd

• Success varies with many factors, including the
  number of embryos that are transferred.
• If one embryo is transferred, there is
  approximately a 7 chance of successful
  implantation with two embryos, the success rate
  increases to 18.
• The rate peaks with the transfer of three to four
  embryos. Presently, the collection of oocytes,
  fertilization, and early embryo growth are
  accomplished with a high degree of efficiency.

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Success rates Contd

• The major hurdles to success are implantation
  after embryo transfer and early pregnancy loss.
  The rate of early pregnancy loss is slightly, but
  not significantly, higher with ART compared to
  spontaneous conception.
• The risk of early pregnancy loss increases with
  age of the female partner. Over age 40, ART
  success rates decline dramatically.
• Pregnancy complications tend to be higher with
  ART pregnancies, primarily because of the much
  higher rate of multiple pregnancy.

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Success rates Contd

• Twins occur in about 25 of ART pregnancies
  versus 1-2of spontaneous pregnancies. The risk
  of more than a twin pregnancy is less than 5.
• To put these figures into perspective, studies
  have shown that the rate of pregnancy in couples
  with proven fertility in the past is
  approximately 20 per cycle. Therefore, although
  a figure of 15-25 may sound low, it is equal to
  or greater than the chance that a fertile couple
  will conceive in any given cycle.

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Cost effectiveness
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