ART……..…State of art

Dr. Yasmin Magdi Abd-Elkreem

Overview of Infertility• According to World Health Organization (WHO) Defines sub-fertility as diminished ability to conceive. Infertility as complete inability to ever conceive.

• Clinically definition of infertility inability to conceive after more than one year of intercourse

without contraception. 10-15% of population is infertile

Requirements for Conception • Production of healthy egg and sperm• Unblocked tubes that allow sperm to reach the egg• The sperms ability to penetrate and fertilize the egg• Implantation of the embryo into the uterus• Finally a healthy pregnancy

Treating Infertility: Assisted Reproductive Technology (ART)

• Assisted reproductive technology (ART): All treatments or procedures that include the in vitro handling of human oocytes and sperm or embryos for the purpose of establishing a pregnancy.

• ART does not include artificial (intrauterine) insemination.

When a couple is sub-fertile or infertile they may need Assisted Reproduction to become pregnant:

• Replace source of gametes– Sperm, oocyte or zygote donors

• Aid in the fertilization process — ICSI, IVF, ZIFT, GIFT.• Aid the implantation process (Putting zygote in correct place) — FET, LH• Replace the uterus

– Surrogate mothers• Pre-implantation genetic screening — PGD, PGS

SELECTING AN ART PROGRAM

1. Pre – IVF work up of the infertile couple Clinical history Examination Investigations Counseling

Why necessary? To identify the cause of infertility and thereby prognosis To identify and correct associated adverse factors before treating primary disorder To decide most appropriate treatment protocol

- Type of drug - starting dosage - expected response and problems

To assess reproductive ageing and plan early access / resort to ART treatments

SELECTING AN ART PROGRAM2. To get adequate number of good quality oocytes

A. Predictors of COHS response Normal responders Hyper responders Hypo- responders - Age, AMH, AFC - Response to earlier COHS - Basal FSH, LH, E2 - BMI, Smoking, Alcohol

- Previous Ovarian Surgery

B. Selection of COHS protocol - Agonist versus Antagonist protocols - Mild stimulation protocols

C. Ultrasound monitoring with power and colour Doppler

D. Biochemical Monitoring

SELECTING AN ART PROGRAM

• When selecting an ART program, information is crucial. Important points for consideration include

1. The qualifications and experience of personnel.2. Types of patients being treated.3. Support services available.4. Cost.5. Convenience, live birth rates per ART cycle started and multiple pregnancy rates.

1. in vitro fertilization (IVF)• Problem is that egg and sperm can’t meet:

– Blocked tubes or abnormal structures– Not enough healthy sperm

• Put sperm and egg together in dish and then implant early embryo into uterus.

• The General Method of IVF1. Monitor egg maturation in the ovary

- Ultrasound- Hormone levels

2. Collect eggs (mother’s own or from donor)- Injection of human chorionic gonadotropin (hCG) and follicle stimulating hormone (FSH) to time egg ripening- Transvaginal aspiration using hollow needle

1. in vitro fertilization (IVF)3. Obtain sperm from father (or donor) and assess quality4. Sperm and oocyte are mixed in Petri dish (D0).5. Nurture embryo growth by incubating in medium containing various nutrients6. Transfer embryos (usually 3-6 Days) to uterus, artificially removing zona pellucida if necessary (“hatching”).

2. Gamete intrafallopian transfer• GIFT should only be performed when sperm level is adequate and at least

one fallopian tube is open and functional. • This allows fertilization to take place inside the woman's body. • The General Method of GIFT: 1. Induction and monitoring .2. eggs are removed from the woman, and placed in one of the

fallopian tubes, along with the man's sperm. • Therefore, this variation is actually an in vivo fertilization, and not an in

vitro fertilization.

3. Zygote intrafallopian transfer• Zygote intrafallopian transfer (ZIFT) is an infertility treatment where a

blockage in the fallopian tubes are the cause. • Similar to GIFT, except the egg is fertilized before it is placed in the

fallopian tube.

• The General Method of ZIFT: 1. Induction and monitoring 2. Oocytes are removed from a woman's ovaries, and in vitro fertilized with collected sperm. 3. The resulting zygote is placed into the fallopian tube by the use of Laparoscopy.

4. intracytoplasmatic sperm injection (ICSI)

• Development of ICSI: Subzonal sperm injection breaching of the oolemma one sperm swim into cytoplasm.

• 1st ICSI baby born in January 1992.• The procedure involves the direct injection of a single sperm into the egg

cytoplasm• grants the best results (fertilization, clinical pregnancy)• Advantages:1. Use of fresh semen or after cryopreservation 2. Cases with immunologic cases with anti-sperm antibody.3. New hope for azoospermia, cryptozoospermia.4. Severe oligozoospermia, severe asthenozoospermia. 4. New hope for cases with previous total fertilization failure after IVF

4. intracytoplasmatic sperm injection (ICSI)

• The General Method of ICSI

5. Frozen-thawed embryo transfer (FET)

• Extra embryos remaining after the embryo transfer may be cryopreserved (frozen) for future transfer.

• In some cases, freeze all cycles and a subsequent frozen-thawed embryo transfer increases their chance to achieve pregnancies.

• No ovarian stimulation is required. • Lower cost than ICSI.

6.Pre-implantation ScreeningScreening for genetic disorders BEFORE pregnancy begins:• One cell of 8 cell embryo is removed • Single cell is karyotyped and probed with FISH for specific genetic

disorders• Pre-implantation Genetic Diagnosis (PGD)• Only genetically “healthy” embryo is implanted.Screen for:

– Large chromosomal abnormalities– Rare Mendelian Disorders– Boys with X-linked disorders

Which Embryo is Disease-Free?

Conclusions………• The decision to seek treatment for infertility is a viable one due to the

assisted reproductive technologies available today.

• Types of ART include in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), intracytoplasmic sperm injection (ICSI), frozen-thawed embryo transfer (FET), embryo cryopreservation, egg or embryo donation, and gestational carriers.

Thank You!For contact: E-mail: Yas.magdi@hotmail.com