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Assisted Conception Assisted Conception
Dr. ZEINAB ABOTALIB MRCOG, DGO,Dr. ZEINAB ABOTALIB MRCOG, DGO,Associate Professor & Associate Professor &
Consultant Obs/Gyna Infertility & IVFConsultant Obs/Gyna Infertility & IVF
Assisted ConceptionAssisted Conception
• IUI: intrauterine insemination• IVF: in vitro fertilization • ICSI: intracytoplasmic sperm injection • GIFT: gamete intrafallopian transfer • ZIFT: zygote intrafallopian transfer • PESA: percutaneous epididymal sperm
aspiration
Assisted ConceptionAssisted Conception
• ET: embryo transfer • TESE: testicular sperm extraction • SUZI: subzonal sperm injection • PGD: preimplantation genetic diagnosis
Assisted ConceptionAssisted Conception
• Objective– To bring sperm and oocyte close to each
other to promote chances of fertilization and, ultimately, achieve a pregnancy
Assisted ConceptionAssisted Conception
• Main types:– IUI: intrauterine insemination– IVF: in vitro fertilization – ICSI: intracytoplasmic sperm injection
Assisted ConceptionAssisted Conception
• Required procedures– Superovulation – Sperm preparation – Assisted fertilization
SuperovulationSuperovulation
• Hormonal manipulation to enhance ovulation and release multiple oocytes during ovulatory cycle
SuperovulationSuperovulation
• Drugs used:• Human menopausal gonadotropin
– Taken from urine of postmenopausal women– Follicle stimulating hormone (FSH) and
luteinizing hormone (LH) activity • Recombinant FSH • Recombinant LH
Superovulation- protocolSuperovulation- protocol
• Gonadotropin for 9-11 days• Monitoring follicular development by transvaginal
ultrasound• Follicles 16 -18 mm in diameter
– 10,000 IU hCG • Oocytes maturation • Ovulation
Sperm PreparationSperm Preparation
• Select PMNS • Remove seminal plasma, WBC, and bacteria • Sperm capacitation
– Coating of sperm with seminal plasma proteins
– Allow sperm to become fertile
– In vivo or in test tube
Intrauterine inseminationIntrauterine insemination
• Sperm sample deposited in uterus just before release of an oocyte (s) in a natural or stimulated cycle
• Soft catheter • Give hCG at injection or up to 24 hrs later• Sperm volume: 0.2-0.3 ml• Pregnancy rates
– Around 15% per cycle
Gamete intrafallopian transfer Gamete intrafallopian transfer
• Laparoscopic technique in which oocyte and sperm placed in fallopian tube, allowing in vivo fertilization
• Procedure– Superovulation– US guided transvaginal oocyte retrieval
• 0.1-0.2 mil sperm with 2-3 oocytes
In vitro fertilization - IVF In vitro fertilization - IVF
• Taking oocytes from woman• Fertilizing them in lab with her partner's sperm • Transferring resulting embryos back to her
uterus 3 or 5 days later
IVF - SuperovulationIVF - Superovulation
• Gonadotropin stimulation • Monitoring follicular development• US guided transvaginal oocyte retrieval• Oocyte fertilization with sperm
IVF - InseminationIVF - Insemination
• Containers used – Test tubes, Petri dishes, multi-well dishes
• Each oocyte inseminated with 0.5-1.0 mil PMNS • Fertilization detected 12-20 hrs later by
presence of – 2 pronuclei in oocyte cytoplasm – 2 polar bodies in perivitelline space
IVF - InseminationIVF - Insemination
• Syngamy (combination of maternal and paternal pronuclei 24 hrs after insemination
• Further cleavages occur at 24 hr intervals
IVF - Embryo transfer IVF - Embryo transfer
• Embryos transferred to uterus on 2nd or 3rd day after in vitro insemination
• 4-8 cells embryos • 2-3 embryos transferred in 20 µl of culture fluid• Transabdominal US to see fluid placed in uterus • Cryopreserve excess embryos
IVF - Luteal support IVF - Luteal support
• Progesterone (P4) necessary for pregnancy maintenance
• Premature luteolysis in some superovulatory regimens
• P4 supplementation until menses occur or woman has positive pregnancy test
Intracytoplasmic sperm injection - ICSIIntracytoplasmic sperm injection - ICSI
• Injection of single sperm into single oocyte in order to get fertilization
• Procedure– Superovulation – US guided transvaginal oocyte retrieval – IVF
• Oocytes injected with sperm using special microscopes, needles and micromanipulation equipment
ICSI - IndicationsICSI - Indications
• Low sperm concentration, motility, abnormal morphology
• Antisperm antibodies• Fertilization failure after conventional IVF • Ejaculatory disorders• absence of vas deferens or obstruction of
ejaculatory ducts
Assisted HatchingAssisted Hatching
• Indications – Couples having IVF with
• Female partner's age over 37• Poor quality embryos
–Excessive fragmentation–Slow rates of cell division
Assisted Hatching – ProcedureAssisted Hatching – Procedure
• Embryo held with a specialized holding pipette• A needle used to expel an acidic solution against
ZP • A small hole made in ZP • Embryo washed and put back in culture in
incubator• ET shortly after hatching procedure
– Hope for the best
Further Advances And Uses Of Assisted Further Advances And Uses Of Assisted Conception TechnologyConception Technology
• Cryopreservation of– Sperm – Embryo– Oocyte– Ovarian tissue
• Growth of human follicles and oocytes in vitro
• In vitro maturation and transplantation of human spermatozoa
Assisted Reproductive Technology (ART)Assisted Reproductive Technology (ART)
Dr. Abdelsalam TalafhaDr. Abdelsalam Talafha
American Board Certified, Comparative American Board Certified, Comparative Veterinary Obstetrics and Gynecology Veterinary Obstetrics and Gynecology
ARTART
• Infertility – Inability to conceive after 1 year of
unprotected and regular sexual intercourse • Primary infertility
– Couples have never had children• Secondary infertility
– Couples initiated conception in the past and then had difficulty
ARTART
• Infertility – Female partner: 35% – Male partner: 35% – Both partners: 20%– Unknown cause: 10%
• Infertility more common with increasing age
ARTART
• USA women infertility rate– Ages 20-24: 4.1%– Ages 25-29: 5.5%– Ages 30-34: 9.4%– Ages 35-39: 19.7%
• 80% of infertility cases can be diagnosed• 85% of cases can be successfully treated
ARTART
• Female infertility– Disorders of ovulation: 27%– Fallopian tube disorders: 22%– Pelvic adhesions: 12%– Endometriosis: 5% to 15% – Hyperprolactinemia: 7%
ARTART
• Male infertility– Abnormal semen parameters
• Count, motility, morphology • Infertility treatment
– Correcting underlying abnormality– ART
Preimplantation Genetic Diagnosis (PGD)Preimplantation Genetic Diagnosis (PGD)
• Identify genetic conditions in embryo before ET – Hemophilia– Cystic fibrosis– Aneuploidy
PGDPGD
• Hemophilia– Hereditary bleeding disorder– Absence of a blood protein essential for
clotting– Types A: lack of factor VIII– Type B: lack of factor IX
PGDPGD
• Cystic fibrosis– Genetic disease– Defective gene causes body to produce
abnormally thick, sticky mucus that obstruct • Lungs• Pancreas
PGDPGD
• Aneuploidy– Having less than or more than normal diploid
number of chromosomes• Monosomy• Trisomy • Triploidy
PGDPGD
• Performed with IVF • 8-cell stage (3 days old) embryo biopsy • Obtain 1-2 blastomeres for genetic
PGDPGD
• Genetic analysis– Multicolor fluorescence in situ hybridization
(FISH) – Polymerase chain reaction (PCR)
FISHFISH
• Detects – Number of chromosomes – Sexing embryos – Sex chromosome aneuploidy – Whole-chromosome paints for detection of
rearrangements and identification of marker chromosomes
– Analyze polar bodies
FISHFISH
• Fuorescent probes that bind to specific chromosomes are labeled with biotin for detection by specific fluorochrome-conjugated antibodies under a fluorescent microscope