Assisted RT

Assisted Reproductive Technology

Dr.Sumeya

Obgectives

The lecture discuss definitions and types of assisted reproductive technology . Ovarian stimulation and follow up of patient

History of ART

1978- first successful birth using In Vitro Fertilization 1984- first successful birth using Gamete Intra Fallopian Transfer 1986-first successful birth using Zygote Intra Fallopian Transfer

Assisted Reproductive Technology

The term ART describes clinical and laboratory techniques used to achieve pregnancy in infertile couples for whom direct correction of underlying causes are not feasible .In principle ,IUI meets this definition .

Assisted Reproductive Technology

all fertility treatments in which both eggs and sperm are handled. In general, ART procedures involve surgically removing eggs from a woman's ovaries, combining them with sperm in the laboratory, and returning them to the woman's body or donating them to another woman.“Procedures are in vitro fertilization (IVF) ,OCR, AZH, ICSI, ZIFT, PGD, GIFT, SSR

Intrauterine insemination (IUI)

Intrauterine insemination (IUI) is performed by introducing a small sample of prepared sperm into the uterine cavity with a fine uterine catheter. This process usually requires mild stimulation with FSH to produce 2–3 mature follicles. Follicular tracking is essential to avoid over or under stimulation. The success rate of this procedure ranges between 15 and 20 per cent in top fertility units.

This type of artificial insemination can be performed in a natural or induce cycle; with clomid alone, Clomid and FSH injection or purely with FSH. If any form of ovulation induction has been used it is also quite H.C.G injection approximately 36 hours prior to the insemination to ensure optimal timing with ovulation .All IUI cycles were accompanied by ovarian stimulation with CC, HMG or recombinant FSH, Ovarian response was monitored by plasma E2, LH concentrations and by ovarian ultrasonography .

Indications for intrauterine insemination

Gross male infertility or sub fertility ( severe oligo-asthenoteratozoospermia), for couples who cannot afford IVF or reject IVF for other reasons

Ejaculatory failure is the classical indication, since the male partner is unable to ejaculate into the vagina

Cervical factor, while cervical mucus hostility is a logical indication for IUI, as it bypasses the mucus in the cervical canal.

Idiopathic/unexplained infertility

Immunological infertility

Endometriosis

Intrauterine Insemination (IUI)

In Vitro Fertilization

This technique has been used extensively in animal embryological research for decades, but only since 1978 has it been successfully applied to human reproduction

Indications of IVF

Originally, IVF was designed for the treatment of severe tubal disease . Another common indication for IVF is low sperm count.

Unexplained infertility; when unexplained infertility does not respond to traditional treatments (clomid or stronger fertility medications combined with artificial insemination) IVF can be an option. IVF may also be used in conjunction with pre-implantation genetic diagnosis, PGD, to determine the presence of certain genetic disorders in embryos. This allows for only the unaffected embryos to be transferred back to the mother.

The Stimulation Phase

Fertility medication :Most fertility medications are agents that stimulate the development of follicles in the ovary. Examples are gonadotropins . In human reproduction the process involves stimulation of the growth of multiple eggs by the daily injection of hormone medications. .

monitoring the cycle

There are five reasons for monitoring the cycle 1- Beforehand, predict the ovarian response to gonadotropins. 2- Monitor the effect of pituitary down-regulation. 3- During the stimulation, evaluate whether the dose of gonadotropin is adequate. 4- Avoid the ovarian hyper stimulation syndrome( OHSS) 5-Identifying adequate follicular development during such stimulation and finally optimizing the time of HCG administration,..

There are five methods for monitoring follicular maturation in ART cycles 1- Serum E2. 2- Ultrasound measurements of follicular growth and endometrial thickness. 3- Ultrasound and serum E2 combined. 4- Perifollicular blood flow by means of power doppler imaging. 5- Perifollicular blood flow using three-dimensional ultrasound.

Ultrasonography in the management of ovulation induction and intrauterine insemination

Endometrial thickness is defined as the maximal distance between the echogenic interfaces of the myometrium and the endometrium, it is an easily measurable ultrasonic parameter and it represents a bioassay of estrogenic activity. On the day before H.C.G injection it is postulated that it may predict the likelihood of implantation, pregnancy rates were significantly higher in the patients with an endometrial thickness > 9 mm compared with those of < 9 mm.An increased rate of early miscarriage with very thin (<6 mm) or thick endometrium (>13) .

Ultrasound scan for ovaries

Sperm preparation
The ideal sperm preparation technique is to achieve the largest number of morphologically normal motile spermatozoa in a small volume of physiological culture media free from seminal plasma, leukocytes and bacteria.


Techniques usually used in in vitro fertilization


(OCR) is the process whereby a small needle is inserted through the back of the vagina and guided via ultrasound into the ovarian follicles to collect the fluid that contains the eggs.

Fertilization And Culture Of The Embryos

Within a few hours after retrieval embryologist will be preparing to fertilize the eggs. This may be done with either traditional IVF or with ICSI. In the former a high concentration of sperm is placed around each egg and they are left together overnight to allow “natural” fertilization to take place. With ICSI – intracytoplasmic sperm injection – actually inject a single sperm into each egg.

Embryo transfer

over the next 48 hours the fertilized eggs – now called embryos – will be left alone in the incubator.. However, embryos will only grow in incubators for 3 to 5 days. At this time, they must be transferred back into the uterus. Embryo transfers may be done either on the third day after retrieval (day 3 transfer) or on the fifth day (referred to as a blastocyst transfer).

Intra-Cytoplasmic Sperm Injection

Intracytoplasmic Sperm Injection (ICSI)

Gamete Intrafallopian Transfer(GIFT)

In gamete intrafallopian transfer is a the technique is similar to IVF, but the harvested eggs and sperm are placed directly into the fallopian tubes, with fertilization occurring in the woman's body

Gamete Intrafallopian Transfer (GIFT)

Gamete Intra-Fallopian Transfer(GIFT

Zygote Inrafallopian Transfer(ZIFT)
The eggs are mixed with partner’s sperm, but wait until fertilization occurs to place the embryos inside fallopian tube.

Zygote Intrafallopian Transfer (ZIFT)

Egg donors

Sperm donation

Preimplantation genetic diagnosis

Preimplantation Genetic Diagnosis (PGD)

Preimplantation genetic diagnosis (PGD)Removal and genetic analysis of a single cell from a 3- to 5-day old embryo Used to select embryos free of genetic disorders for implantation and development.Removal of one cells does not affect growth of the embryo in any way—the cells have not yet been activated to become a specific organ of the body

Preimplantation Genetic Diagnosis (PGD)

Fig. 16-12, p. 364

Surgical sperm retrieval

Where the sperm quality is low but sperm are present, ICSI is required to help achieve a pregnancy. However, in the absence of naturally ejaculated sperm, patients will have to undergo surgical sperm retrieval (SSR). SSR can be performed under sedation or general anaesthetic. 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.

Cryopreservation of gametes

Sperm or oocyte can be cryopreserved for later use. Often this process is very useful in preserving fertility for patients undergoing chemo/radiation therapy for cancer. Currently, the pregnancy rate for thawed sperm/egg in top fertility centres is very near to that of normal IVF cycles. This process can also be used for storage of gametes from donors who wish to donate their sperm or eggs for altruistic reasons to help couples with fertility problems.

Frozen Embryos

Frozen embryos: Specialists may freeze additional embryos from a woman's cycle for later use. They may also freeze embryos of a donor in order to have them ready to place in a surrogate mother's uterus at the appropriate moment in the surrogate's natural or hormone-replaced cycle.

ART Procedures

The Complications Of IVF
Serious complications from IVF are rare. In general, complications can be divided into 4 categories: complications from retrieval, hyperstimulation, multiple pregnancies, and emotional stress.

THAK YOU