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IVF

IVF. Dr. H. R. Muharam, SPOG (K). Introduction. In vitro fertilization ( IVF ) is a process by which egg cells are fertilised by sperm outside of the womb, in vitro . IVF is one method of assisted reproductive technology. No cause. More than one. Male factor. Endometriosis.

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IVF

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  1. IVF Dr. H. R. Muharam, SPOG (K)

  2. Introduction • In vitro fertilization (IVF) is a process by which egg cells are fertilised by sperm outside of the womb, in vitro. • IVF is one method of assisted reproductive technology

  3. No cause More than one Male factor Endometriosis Dysovulation Unexplained Tubal factor Figure 1 The causes of infertility in a large observational multicenter study in the UK, 2003 McVeigh,ASRM, 2004

  4. * In these situations intrauterine insemination treatment merits consideration before proceeding to IVF

  5. Introduction • The first IVF baby in the world (Louise Brown) was born in July of 1978 in England. • Louise Brown was 28 when she delivered her own baby in 2006. Her baby was conceived without IVF. Hundreds of thousands of children are now born annually as a result of the IVF technique

  6. The process involves : • Hormonally controlling the ovulatory process • Removing ova (eggs) from the woman's ovaries • Letting sperm fertilise them in a fluid medium. • The fertilised egg (zygote) is then transferred to the patient's uterus with the intent to establish a successful pregnancy

  7. Problems of the fallopian tube, but it turned out that it was successful in many other infertility situations as well. • The introduction of intracytoplasmic sperm injection (ICSI) addresses the problem of male infertility to a large extent. • This means that IVF can be used for females who have already gone through menopause.

  8. Indication • An anatomic problem with the uterus, such as severe intrauterine adhesions • Blocked fallopian tubes or pelvic adhesions • tubal reversal surgery • vasectomy reversal surgery • Male factor infertility (low sperm count or low motility). • ICSI is an IVF procedure that can fertilize eggs even with poor sperm quality. • Failed 2-4 cycles of ovarian stimulation with intrauterine insemination • Advanced female age - over about 38 years of age. • Severe endometriosis • Unexplained infertility when inseminations have failed - unexplained infertility means standard fertility tests have not found the cause of the fertility issue

  9. Method Ovarian stimulation • Started on the third day of menstruation and consist of a regimen of fertility medications to stimulate the development of multiple follicles of the ovaries • Monitoring • Estradiol • USG, follicular growth. Typically approximately 10 days of injections will be necessary. • Spontanenous ovulation during the cycle is prevented by the use of GnRH agonists or GnRH antagonists, which block the natural surge of luteinising hormone (LH).

  10. Stimulation protocol Three types of drugs: • GnRH-agonist (gonadotropin releasing hormone agonist) or a GnRH-antagonist (e.g. Ganirelix) to suppress the LH surge and ovulation until the follicles are mature • FSH product (follicle stimulating hormone) to stimulate development of multiple follicles • HCG (human chorionic gonadotropin) to cause final maturation of the eggs in the follicles • The purpose of the GnRH-agonist (or antagonist) is to suppress release of LH (luteinizing hormone) from the woman's pituitary gland during the ovarian stimulation process. LH surges would cause premature ovulation (release) of the eggs. • The purpose of the FSH product is to stimulate development of multiple follicles (structures that contain eggs) in the ovaries.

  11. Ovarian Stimulation Protocols Using GnRH-agonists • "Long protocols", also called "luteal Lupron", or "down regulation" protocols • "Flare" protocols, also sometimes called "short" protocols

  12. Long Protocol IVF Hari pertama haid lapor Buserelin nasal 3 kali setiap hari Transfer embrio Ovum Pick up hCG malam Suntikan gonadotropin Tes urin Tiap hari 1 3 21 36 jam ± 2 mg 2 hari 14 hari ± 2 mg Pemeriksaan USG vag Hormonal Usg vag darah Suami siap

  13. Egg retrieval • When follicular maturation is judged to be adequate, • human chorionic gonadotropin (β-hCG) is given. • Acts as an analogue of luteinising hormone • The eggs are retrieved from the patient using a transvaginal technique involving an ultrasound-guided needle piercing the vaginal wall to reach the ovaries. • The retrieval procedure takes about 20 minutes and is usually done under conscious sedation or general anesthesia

  14. Ovum Pick Up • Aspirasi folikel • Pencarian sel telur

  15. Fertilisation • Eggs are stripped of surrounding cells and prepared for fertilisation., • Semenis prepared for fertilisation by removing inactive cells and seminal fluid. • The sperm and the egg are incubated together (at a ratio of about 75,000:1) in the culture media for about 18 hours. • By that time fertilisation should have taken place • The fertilised egg would show two pronuclei. • In situations where the sperm count is low, a single sperm is injected directly into the egg using intracytoplasmic sperm injection (ICSI). • The fertilised egg is passed to a special growth medium and left for about 48 hours until the egg has reached the 6-8 cell stage.

  16. ICSI Intracytoplasmic Sperm Injection diperlukan hanya 1 sperma motil saja untuk disuntikkan kedalam ooplasma

  17. Perkembangan Embrio

  18. Perkembangan Embrio

  19. Perkembangan embrio

  20. Perkembangan Embrio

  21. Simpan Beku • Sperma • Embrio

  22. Selection • Laboratories have developed grading methods to judge oocyte and embryo quality • Typically, embryos that have reached the 6-8 cell stage are transferred three days after retrieval or embryos are placed into an extended culture system with a transfer done at the blastocyst stage, especially if many good-quality day-3 embryos are available. • Blastocyst stage transfers have been shown to result in higher pregnancy rates.[1]. In Europe, transfers after 2 days are common.

  23. Sperma Suami • Persiapan sperma suami

  24. ICSI Intra Cytoplasmic Sperm injection

  25. Pengelolaan embrioKonvensional

  26. Embryo Transfer • Embryos are graded by the embryologist based on the number of cells, evenness of growth and degree of fragmentation. • The number to be transferred depends on the number available. • In the UK and according to HFEA regulations • > 40 may have up to three embryos transferred, • Younger women may have many embryos transferred based on individual fertility diagnosis. • Most clinics and country regulatory bodies seek to minimise the risk of pregnancies carrying multiples. • The embryos judged to be the "best" are transferred to the patient's uterus through a thin, plastic catheter, which goes through her vagina and cervix.

  27. Transfer embrio • Penentuan hari transfer • Persiapan transfer embrio

  28. Transfer Embrio

  29. Complications • The major complication of IVF is the risk of multiple births.[2] • Increased risk of pregnancy loss, • obstetrical complications, prematurity, and • neonatal morbidity with the potential for long term damage • Spontaneous splitting of embryos in the womb after transfer can occur, but • Ovarian stimulation is the development of ovarian hyperstimulation syndrome.

  30. Monitoring Pasca Transfer Embrio • Luteal suppport • USG • Monitoring sampai 12 minggu

  31. Komplikasi • Ovarium hiperstimulasi • Kehamilan ektopik • Perdarahan

  32. Table 32.3. Impact of cause of infertility on livebirth rate from IVF. Templeton AA, et.al, Lancet 1996

  33. Pregnancy Rate on indication Yasmin 2007

  34. Correlation between female age and pregnancy rate 1427 IVF cycles in UK in 2003

  35. Pregnancy Rate on Diff. AgeYasmin IVF 2007

  36. THANK YOU

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