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Assisted Reproductive Technology

Assisted Reproductive Technology. ART. Infertility Female partner: 35% Male partner: 35% Both partners: 20% Unknown cause: 10% Infertility more common with increasing age. ART. Infertility Inability to conceive after 1 year of unprotected and regular sexual intercourse

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Assisted Reproductive Technology

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  1. AssistedReproductive Technology

  2. ART • Infertility • Female partner: 35% • Male partner: 35% • Both partners: 20% • Unknown cause: 10% • Infertility more common with increasing age

  3. ART • 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

  4. GREGORY PINCUS • 1934 First in vitro fertilization of rabbit eggs • Criticized as “mad scientist” • Developed oral contraceptives in 1950’s

  5. Dr. John Rock1890-1984 • 1936 First doctor to open a Rhythm clinic in Boston • 1944 First IVF; created four embryos in secret • 1954 Collaborated with Pincus on U.S. clinical trials of the pill

  6. STEPTOE AND EDWARDSBirth of Louise BrownFirst IVF Baby, 1978

  7. REPRODUCTIVE CHRONOLOGY • 1934 Gregory Pincus: First animal IVF • 1944 John Rock: First human IVF • 1960 FDA approves “the pill” • 1978 First IVF baby • 2001 421 U.S. ART clinics with 41,000 live births annually

  8. ART • 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

  9. Causes of Infertility

  10. Male Infertility

  11. le tecniche • Inseminazione intrauterina • FIVET • ICSI • Crioconservazione ovocitaria e/o embrionaria • IVM

  12. Title • In realtà ognuna di queste “tecniche” prevede l’intervento di più esperti delle diverse componenti che contribuiscono alla completezza del processo. • Le “tecniche” dovrebbero essere applicate conoscendo il più possibile il quadro patologico a cui si stanno applicando. • Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Vivamus et magna. Fusce sed sem sed magna suscipit egestas. • Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Vivamus et magna. Fusce sed sem sed magna suscipit egestas.

  13. Assisted Conception • Techniques designed to assist couples in their effort to procreate • Reason • Identification and correction of female, male or a combination of both infertility causes

  14. Assisted Conception Objective • To bring sperm and oocyte close to each other to promote chances of fertilization and, ultimately, achieve a pregnancy

  15. Assisted Conception Required procedures • Superovulation • Sperm preparation • Assisted fertilization

  16. Superovulation • Hormonal manipulation to enhance ovulation and release multiple oocytes during ovulatory cycle

  17. Superovulation Drugs used: • Human menopausal gonadotropin • Taken from urine of postmenopausal women • Follicle stimulating hormone (FSH) and luteinizing hormone (LH) activity • Recombinant FSH • Recombinant LH

  18. Superovulation- 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

  19. 1.Artificial Insemination • Intravaginal insemination. • Intracervical insemination. • Intrauterine insemination. • Intratubal insemination.

  20. Indagini diagnostiche di base • Esame seminale con test di capacitazione • (2 esami a distanza di due mesi e in laboratorio adeguato!!!) Recupero di almeno 5 milioni di spermatozoi mobili prima del trattamento e 1.500.000 dopo trattamento • Esami ormonali, ecografia, tampone vaginale • Isterosalpingografia: molto sensibile in popolazioni a basso rischio, meno sensibile in popolazioni a rischio • Se ISG dubbia o patologica, laparoscopia e cromosalpigoscopia

  21. Sperm Preparation • Select PMNS (Progressively motile normal sperm) • 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

  22. Intrauterine Insemination • Sperm sample deposited in uterus just before release of an oocyte (s) in a natural or stimulated cycle using a 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

  23. In Vitro Fertilization (IVF) • The first successful IVF case was in 1978 when a British woman delivered a baby called Louise Brown in 28 of July 1978 in Oldam in England by cesarean section. • It had taken nearly a century of research to achieve that.

  24. IVF Indications: • -Women with blocked fallopian tubes • -Ovulation problems • -Seminal problems for the man: sperm transport, motility…… • -Unexplained infertility cases. • -Presence of seminal antibodies in the woman’s body

  25. FIV-ET “classica” - indicazioni • Fattore tubarico – pelvico • Endometriosi moderata – severa • Fallimento iter terapeutico (maschile lieve, PCO, inspiegata)

  26. IVF • Procedure • Superovulation • Insemination • Embryo transfer • Luteal support

  27. IVF

  28. IVF What are the steps done in IVF? • 1- Ovarian stimulation • 2- Vaginal ultrasound: • - monitor the number and size of the follicles . • - adjust the dose of the injections accordingly. • 3- HCG Hormone injection is given for final maturation of the eggs. • 4- Oocytes (eggs) retrieval is done 34-37 hours after taking the HCG injection. • 5-The fluid collected from the follicles in special tubes is examined by the embryologist and the eggs are isolated. • 6-The semen sample is taken in the same day and the eggs fertilized either using the conventional IVF or ICSI

  29. FIV-ET “classica” • Pick up: 34 – 36 ore dopo la soministrazione di hcg; preferibile la sedazione profonda • Sala operatoria idonea • Aghi mono o bi-via • Lavaggio del follicolo: ininfluente • Profilassi antibiotica: non utilizzata da molti. Preferibile in casi selezionati: endometriosi severa, pregresse PID • età media 36 aa PR 34%; IR 14%

  30. Title • Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Vivamus et magna. Fusce sed sem sed magna suscipit egestas. • Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Vivamus et magna. Fusce sed sem sed magna suscipit egestas.

  31. FIV-ET “classica” • C’è un trend generalizzato (soprattutto in Italia) ad eseguire meno FIVET e più ICSI • Per nessuna indicazione, tranne i fattori maschili severi, la ICSI ha risultati migliori • Donne over 40? C’è la tendenza a fare una ICSI

  32. FIV-ET “classica” • Idoneità strutture • Contiguità sala operatoria – laboratorio • Qualità degli ambienti • Personale previsto dalle Linee Guida • Regolamenti europei, nazionali, regionali • Programma di crioconservazione: reso obbligatorio dalla legge 40/2004.

  33. IVF - 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

  34. 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

  35. ICSI:Intracytoplasmic Sperm Injection • 1988: prima icsi; 1992 Palermo G. prima gravidanza da icsi • Fattore maschile severo • Anticorpi antispermatozoi (Mar, Immunobead, ecc...)‏ • Azoospermia ostruttiva e secretoria • Pazienti oncologici • Lesioni midollari • Precedenti non fertilizzazioni in FIVET • Precedenti fallimenti FIVET

  36. ICSI - 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

  37. ICSI strumentazione aggiuntiva • Micromanipolatore • Holding pipette e injection pipette • Microscopio invertito a 200 o 400 x • Piano antivibrazioni

  38. Methods For Improving IVF • -Transfer embryos at blastocyst stage • -Culture fertilized ova and early embryos with cells that normally surround the oocyte, so they can provide growth factors. • -Screen early embryos for chromosome abnormalities and implant only those with normal karyotypes.

  39. Assisted Hatching Indications • Couples having IVF with • Female partner's age over 37 • Poor quality embryos • Excessive fragmentation • Slow rates of cell division

  40. 4.Assisted Hatching : • Indications: • -Repeated implantation failure in special cases • when the wall of the Embryo is thick

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