In Vitro Fertilization

1. By: Amrusha Bhatt, Vandan Jhaveri, Ananya Jhamb, Teja Mourya Bayyarapu, Divyansh Sharma and Kevin Pathinather In Vitro Fertilization

2. Background

3. Background • First successful In Vitro Fertilization was done in Britain, in the 1978s by Robert Edwards, a physiologist and Patrick Steptoe, a gynecologist Patrick Steptoe Robert Edwards

4. Background • The first IVF baby was born in 1978, named Louise Brown • The original patients had undergone natural IVF, meaning they were not given fertility drugs instead they were monitored very closely • Two years later, two Australian groups performed successful IVF however, the patients were given fertility drugs

5. Background • The Australian group’s success rate was 5% higher per attempt than that of Edwards and Steptoe • In the 1980s, many improvements were made to the culturing technique, fertility drugs, and safer way to retrieve eggs with a vaginal ultrasound probe instead of laparoscopy • By the end of 1980, the success rate reached 20-25% per attempt for women under the age of 40s

6. Background • In the 1990s, improvements in treatment protocols for women above 40 years old and the development of ICSI (Intracytoplasmic perm Injection) • With ICSI a single sperm can be injected into an egg to achieve fertilization

7. Method

8. Method • Menstrual cycle control • The patient is given birth control pills (BCP) on the day a period starts. This is continued for 10- 35 days. • After 10- 35 days, a Lupron (a medicine that keeps the pituitary gland at rest) is taken

9. Method 2. Stimulation of follicular development • Vaginal ultrasound exam is done to make sure the pituitary gland has been successfully suppressed and that the ovaries are ready for stimulation • The use of fertility drugs in preparation of Follicle Stimulating Hormone (FSH), such as Follistim, Gonal-F, Repronex, Humagon,and Fertinex

10. Method • Usually a combination of two of these medicines are taken in the form of daily injection for 7-10 days 3. Monitoring the cycle • Many visits to the specialist • Blood test is done to measure estradiol • Vaginal ultrasound to count and measure the follicles

11. Method 4. Egg retrieval (ER) • Takes place 36 hours after the HCG • A needle guided by ultrasound is used to pass through the top wall of the vagina and into the fluid filled egg sacs (follicles) in the ovary. This takes about 15 minutes and causes no pain. • The fluid removed is given to the embryologists

12. Method 5. Fertilization • The sperm and egg are put together at a ratio of about 75000:1 in the culture media for about 18 hours (wait for the egg to fertilize) • The fertilized egg is put into special growth medium until the egg consist of 6-8 cells

13. Method 6. Embryo culture • Involves providing nucleotides, amino acids, glucose, vitamins and cholesterol for the embryonic growth and development 7. Embryo selection • The cells are examined under a microscope and the best of those will be chosen, in order to avoid inheritable diseases

14. Method 8. Embryo transfer • transferred to the patient's uterus through a thin, plastic catheter, which goes through her vagina and cervix

15. Process

16. Ethics

17. Ethics • Laboratory mix-ups, resulting in unexpected deliveries or the wrong baby being delivered, have been an issue, and measures have been taken to prevent this from happening: • A woman in California delivered a baby that belonged to another couple, and was notified as such after the delivery process occurred. • A process by HFEA (Human Fertilization and Embryology Authority) requires all clinics to test the identity of the specimen twice at each stage the specimen are transferred, and this is being done more and more technologically to reduce human error.

18. Ethics • In vitro fertilization allows for pregnancy to take place after menopause, when the womb is still very much capable of harbouring a foetus. Although there is no genetic connection with the offspring, the mother gains an emotional connection through her pregnancy, child birth, and infant years • This process of fertilization also permits same-sex couples, unmarried parents, and single parents, to harbour children

19. Ethics- Case • Case North Coast Women's Care Medical Group vs. Superior Court, a medical assistant sues two doctors when they refuse to inseminate for a lesbian couple on the religious grounds. The case won in favour of the lesbian couple.

20. Ethics-Case • Nayla Sulemen (America’s Octomom) had 6 embryos implanted, two of which split, resulting in the delivery of octuplets. The doctor that approved the procedure is being seeked to by California State government to strip him of his license on the grounds that Sulemen was not equipped to raise as many as 6 children, let alone 8

21. Ethics • The catholic church objects the entire embryo-planting process. They claim a child is the product of a married man and woman and should be the conceived under no other circumstances, and that artificial insemination removes the idea of a child being born after a married couple completely give themselves to each other and involve themselves in the closest intimacy.

22. Availability • In the USA, in 2005, there were 2.5 IVF (in vitro fertilization) physicians for every 100,000 of the population • Finiancial restrictions also play a role in availability. An IVF cycle can cost anywhere from $12,500 in the US to $4000 in Japan • There are age-oriented restrictions include most clinics do not serve women over the age of 50 or 55, making it difficult for women over that age to get treatment

23. Legal Status • In Iran, married couples are only lawfully allowed to donate a fertilized egg to another married couple • In Costa Rica, a complete ban on all IVF is in effect, claiming that IVF is unconstitutional, as it violates life

24. Legal Status • Major restrictions were set in place in Australia before 2002 on single, infertile women for IVF treatments, but ever since the Leesa Meldrum case, these laws have been changed and it has been made easier for these types of women to get the desired treatment • Various states in the US, such as Tennessee, have attempted to label IVF treatments as adoption, but have failed on the federal level

25. Pros & Cons

26. Positive Aspects • This procedure can aid those who have reproduction problems to fertilize effectively for insertion in the woman’s body so she can successfully deliver a baby. • Despite the negative draw backs (discussed in the following slides), the end result, if successful, provides the couple with a baby which they would not be able to produce otherwise.

27. Negative Aspects • The process may not work for everyone as the age of the woman may restrict the successful completion of the fertilization of the egg. This occurs as a result of the decline in the conditions of the eggs once the woman is around mid-thirties.

28. Negative Aspects • There can be severe side effects on the woman due to the utilization of fertility drugs. Women are at a risk of developing OHSS, short for Ovarian Hyperstimulation syndrome, when they form a high number of follicles causing an increase in their blood estrogen levels. (Follicles: group of cells containing a cavity) OHSS can cause negative effects such as dehydration and nausea. Although it can harmful it is still a non-life threatening syndrome.

29. Negative Aspects • There is a high chance of multiple birth rates as more than one fertilized egg is inserted into the womb in hopes that at least one is successful. However, there are chances that more than one infant will be produced and not everyone can be financially and mentally prepared to raise multiple infants. (Some countries, such as the UK, have restrictions on the number of embryos that may be inserted into the woman)

30. Negative Aspects • Another con is the high cost and some couples may have to undergo the procedure for multiple times until it proves to be successful.

31. Societal Aspects

32. Economic Aspect • The high financial requirements needed for the successful completion of In Vitro Fertilization causes some households to deteriorate economically. Several attempts may have to be made until the successful fertilization of the implanted egg.

33. Social and Moral Implications • After the birth of the baby, society may not consider it to be a true wonder of life due to its artificial insemination rather than one being born naturally. • Several moral oppositions to this process as some argue that an embryo should be conceived naturally, rather than artificially.

34. Environmental Aspect • Environmental implications can cause problems for the woman as hazardous conditions may risk the life if the baby. However, not so hazardous conditions may also create negative effects for the woman and the offspring. Example: The variation in seasons may cause a decrease in the success of IVF.

35. Factors to Consider in IVF • Age: Age is a major factor when considering in vitro fertilization. Woman may try IVF if they are of 35 years or younger and do not have any problems with their partner’s sperm. • Multiple Births: Couple’s who are not expecting more than a single child and cannot take care of multiples should take time and plan carefully about what they are doing. Statistics show that when IVF is used to establish a live birth, approximately 63% are single babies, 32% are twins, and 5% are triplets or more.

36. Factors to Consider in IVF • Cost: The cost of IVF is very high and one again, this is a major factor to consider. Couple’s that are struggling financially or cannot support a child should not use the money they have on IVF. One cycle of IVF costs an average of $12,400. • Reduced surgery: Research well into IVF and find out what, if any way, you can maybe spend less or can reduce surgery. If a woman has IVF, she may not have to undergo surgery on her fallopian tubes. It is estimated that the IVF technique has reduced such surgeries by half.

37. Factors to Consider in IVF • Safety: Studies suggest that in vitro fertilization is safe. A recent study covered nearly 1,000 children conceived through these methods in 5 European countries and found that the children, monitored from birth to age 5 years, were as healthy as children conceived naturally. However, other studies have found a slightly increased risk of genetic disorders in children conceived through assisted reproductive technologies.

38. Alternatives

39. Alternative Techniques • Gamete intrafallopian transfer (GIFT): GIFT is similar to IVF. It is used when a woman has at least one normal fallopian tube. Eggs are placed in this tube along with a man's sperm to fertilize there.

40. Alternative Techniques • As with most fertility procedures, success depends on the couple's age and the woman's egg quality. It is estimated that approximately 25-30% of GIFT cycles result in pregnancy, with a third of those being multiple pregnancies. • The first baby that was conceived using this procedure was in UK on 23rd October 1986, called Todd Holden.

41. Alternative Techniques • Zygote intrafallopian transfer (ZIFT): ZIFT is tubal embryo transfer in which a woman's eggs are taken from her ovaries, fertilized in the laboratory, and put back in the fallopian tubes rather than the uterus.

42. Alternative Techniques • Intracytoplasmic sperm injection-This procedure occurs, when the male has a low sperm count, hence, the single sperm is directly, injected in the egg, so fertility may occur. • This process occurs under a microscope using multiple micromanipulation devices.

43. Alternative Techniques • A pipette stabilizes the oocyte and there is a suction applied, and from the opposite side of the microscope glass the micropipette, collects a single sperm cell, by immobilizing it, hence, it not moving by cutting, its tail off. • Then the micropipette pierces through the oocyte, and its cytoplasm, hence, injecting the sperm cell, and the following day, as it is checked, the egg is now fertilized.

44. Statistics

47. Bibliography • "Catechism of the Catholic Church". Vatican. 1993. http://www.vatican.va/archive/catechism/p3s2c2a6.htm#III.Retrieved 2008-11-25. "sections 2376-2379"  • Chambers GM, Sullivan EA, Ishihara O, Chapman MG, Adamson GD (June 2009). "The economic impact of assisted reproductive technology: a review of selected developed countries". Fertil.Steril.91 (6): 2281–94

48. Bibliography • Haas, John M., Ph.D., S.T.L.. "Begotten Not Made: A Catholic View of Reproductive Technology • Hammoud AO, Gibson M, Stanford J, White G, Carrell DT, Peterson M (2009). "In vitro fertilization availability and utilization in the United States: a study of demographic, social, and economic factors". Fertility and Sterility91 (5): 1630–1635

49. Bibliography • "Hull becomes the latest clinic to guard against IVF mix ups". Private Healthcare UK. 2008 • The Ethics Committee of the American Society for Reproductive Medicine. Fertility and Sterility, Volume 92, Issue 4, Pages 1171–1500, e43-e58

50. Thank you for watching. THE END