Assisted Reproduction

Technology

                    
    

Presented by
Abdulkareem Sultan Al-Olama 1
 Introduction
 Infertility is a very common condition
affecting approximately 13-14% of
couples in the reproductive age group.
 Although this prevalence has remained
stable over the last few years, the
demand for infertility services has
increased substantially.
 This increase is due primarily to the
Baby Boom generation entering into the
reproductive age group at a time of
highly publicized technological
advances.
Abdulkareem Sultan Al-Olama 2
Topics of Discussion
 Definition of Infertility & ART
 Common causes of infertility
 Who is eligible for ART
 Methodology of ovulation induction
 Improving SPA
 Other techniques
 Counseling couple

Abdulkareem Sultan Al-Olama 3

Topics of Discussion Cont’d
 Failure rate
 Cost effectiveness

Abdulkareem Sultan Al-Olama 4

Definition of Infertility &
ART
 Infertility is defined classically as
the inability to conceive after 1
year of unprotected intercourse.
This definition is based on the
cumulative probability of
pregnancy:

Abdulkareem Sultan Al-Olama 5

 Definition of Infertility &
ART Cont’d
Month Monthly Probability Cumulative Probability
1 0.2 0.20
2 0.2 0.36
3 0.2 0.49
4 0.2 0.59
5 0.2 0.67
6 0.2 0.74
7 0.2 0.79
8 0.2 0.83
9 0.2 0.86
10 0.2 0.89
11 0.2 0.91
12 0.2 0.93
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Definition of Infertility &
ART Cont’d
 ART refers to all techniques
involving direct retrieval of oocytes
from the ovary
 ART procedures include IVF,
GIFT, ZIFT, and ICSI.
 The simplest ART procedure, IVF
has been around for over 20 years
and is perhaps the most commonly
recognized ART of all procedures.
Abdulkareem Sultan Al-Olama 7
 Common causes of
infertility

Causes of Infertility
Cause Couples Women
Male 35% N/A
Ovulatory 15% 40%
Tubal 35% 40%
Unexplained 10% 10%
Other 5% 10%

Abdulkareem Sultan Al-Olama 8

Common causes of
infertility Cont’d
 Female factors
 Cervical factor
 Ovulatory factor (PCOs)

 Uterine factor (endometriosis)

 Pelvic factor

Abdulkareem Sultan Al-Olama 9

Common causes of
infertility Cont’d
 Polycystic Ovarian Syndrome
(PCOS)
Also known as Stein-Leventhal syndrome
 Also known as hyperandrogenic chronic
anovulation is a benign disorder that
commonly results in infertility.
 PCOS is characterized by irregular
ovulation and menses, obesity, insulin
resistance, acne, and hirsutism.
 Most women with PCOS also have
ovaries filled with multiple benign cysts.

Abdulkareem Sultan Al-Olama 10

Common causes of
infertility (PCOS) Cont’d
 How does PCOS contribute to
Infertility?
 Impaired fertility is a prominent feature of
PCOS.
 This is believed to result from elevated
insulin levels that stimulate excess
androgen production by the ovaries.
 The androgens cause premature follicular
wasting which causes inconsistent or
absent ovulation, which is associated
with infertility.

Abdulkareem Sultan Al-Olama 11

 Common causes of
infertility (PCOS) Cont’d
Diagnosis: 1. Symptoms
 Irregular or absent periods

 Lack of ovulation

 Weight gain

 Hirsutism (excessive hair growth)

 Insulin resistance

 Acne

 Male-pattern balding

 Multiple small ovarian cysts-these may be

seen by an ultrasound examination
 Ancthosis nigrans (darkening of the skin at the
nape of the neck and under the arms and
breasts).

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 Common causes of
infertility (PCOS) Cont’d
Diagnosis: 2. Blood Work/Hormonal Testing:
 Laboratory testing is important for
diagnosis but it is crucial to look
at multiple values collectively.

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 Common causes of
infertility (PCOS) Cont’d
Diagnosis: 3. Ultrasound:
 Ultrasound of the pelvis is typically
performed when the clinician suspects
PCOS.
 If >10 cysts are found in either ovary that
are less than 10mm, this meets the
ultrasound criteria for PCOS.
Furthermore, polycystic ovaries are
typically 1.5 to 3 times the normal size.
 Just the presence of polycystic ovaries,
without symptoms and/or consistent blood
work, does not confirm a diagnosis of
PCOS.

Abdulkareem Sultan Al-Olama 14

Common causes of
infertility (PCOS) Cont’d
 Treatment
 Weight Loss, Progestins, Oral
Contraceptives, Anti-
Androgens, GnRH agonists,
Fertility drugs, Surgical therapy:
 a) Ovarian wedge resection
 b) Laparoscopic ovarian drilling

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Common causes of
infertility Cont’d
 Endometriosis
 Endometriosis can be defined as a
nonmalignant disorder in which
functioning endometrial tissue is present
outside the uterus.
 The incidence of this disease ranges
from 10-15% in women between the ages
of 25 and 44 who are actively
menstruating, but it also occurs in
teenagers.
 It is estimated that 25-50% of infertile
women have this disease.

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Common causes of
infertility (Endometriosis) Cont’d
 The incidence is higher in first
degree relatives of women with
endometriosis, which suggests that
heredity may play a role.
 In addition, there is also a higher

prevalence of the disease in

women who delay childbearing or
who are of Asian descent.

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Common causes of
infertility (Endometriosis) Cont’d
 Causes and Symptoms
 The cause of endometriosis is unknown,
however there are several theories.
 The first theory is known as retrograde
menstruation, or the movement of sloughed
endometrial tissue back through the fallopian
tubes and into the abdominal cavity. This
tissue can then attach itself to various internal
organs or tissues outside of the uterus.
 Immune system dysfunction. It is believed
that certain women may develop
endometriosis due to deficiencies in their
immune system.

Abdulkareem Sultan Al-Olama 18

Common causes of
infertility (Endometriosis) Cont’d
 In women without endometriosis, the
immune system destroys any ectopic
implants that may develop. However, in
women with endometriosis, there is an
altered immune response and the body is
unable to destroy the growth of the implants.
 Furthermore, some scientists believe that
endometriosis is an autoimmune disorder.
This means that the body makes antibodies
to endometrial cells. These antibodies may
destroy the healthy endometrium found in
the uterus, but are ineffective in destroying
ectopic implants.

Abdulkareem Sultan Al-Olama 19

Common causes of
infertility (Endometriosis) Cont’d
 Symptoms
 Pelvic pain and cramping before
and during periods
 Pain during intercourse

 Inability to conceive

 Fatigue

 Painful urination during periods

 Gastrointestinal symptoms such as

diarrhea, constipation, and nausea

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Common causes of
infertility (Endometriosis) Cont’d
 There are other medical conditions that have
similar symptoms and should be considered
prior to making a diagnosis of endometriosis.
Conditions that may cause generalized pelvic
pain include:
 Pelvic inflammatory disease (PID)
 Pelvic adhesions
 Neoplasms (cancers), both benign or
malignant
 Ovarian torsion
 Sexual or physical abuse
 Other causes that are not gynecologic in
nature

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Common causes of
infertility (Endometriosis) Cont’d
 How does endometriosis contribute to
infertility?
 The cause of infertility is believed to
result from the scarring and adhesions
that form in the reproductive tract as a
result of inflammation.
 Scar tissue and adhesions may reduce
fertility by either obstructing or distorting
the shape of the fallopian tubes, which in
turn impedes the passage of sperm to the
egg.

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Common causes of
infertility (Endometriosis) Cont’d
 In the event that sperm do reach
the egg, they may encounter a
hostile environment unfavorable to
fertilization.
 Finally, scarring from

endometriosis may obstruct the

fallopian tubes so that if an egg is
fertilized, it may be unable to travel
to the uterus for implantation.

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Common causes of
infertility (Endometriosis) Cont’d
 Diagnosis
 One of two techniques may be used to
confirm the diagnosis of endometriosis.
Both procedures involve visualization of
the pelvic cavity in order to confirm the
presence or absence of ectopic implants.
 laparoscopy
 laparotomy
 If there are any suspected ectopic
implants, they are biopsied in order to
determine the presence of endometrial
cells.

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Who is eligible for ART
 Women with tubal diseases
 Unexplained infertility
 Endometriosis
 Immunologic causes for infertility
 Women with premature ovarian
failure
 Individuals with male factor infertility
(e.g., abnormalities in sperm production,
function or transport or prior vasectomy)

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Methodology of ovulation
induction Cont’d
 Basically, this term refers to the use of
medications to stimulate your body to
produce one or more eggs.
 Ovulation induction can be as simple as
taking a daily pill or more complicated, like
injecting fertility medications and seeing
your specialist daily for necessary
monitoring. The simplest form of ovulation
induction involves taking clomiphene.

Abdulkareem Sultan Al-Olama 26

Methodology of ovulation
induction Cont’d
 More potent medications, known as the
gonadotropins, are available for more
intensive ovulation induction.
 Gonadotropins are injectable medications
that are made up of a combination of follicle
stimulating hormone (FSH) and luteinizing
hormone (LH) or just FSH alone.
 These hormones can be very helpful in
getting a woman to produce and release her
eggs.

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Methodology of ovulation
induction
 The success of ovulation induction in
achieving a pregnancy is highly
variable. It depends on the diagnosis,
age, the medication being used, and
numerous other factors.

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Improving SPA

 Sperm penetration assay (SPA) is a

multi-step laboratory test that offers a
biological assessment of human sperm
fertilizing ability.

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Other techniques
 ZIFT
 GIFT
 TEST
 POST
 ICSI
 TESE
 MESA

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Other techniques Cont’d
 ZIFT
 Zygote Intrafallopian Transfer. ZIFT may
be recommended if the husband has
severe male fertility factor or if there has
been difficulty confirming fertilization with
past procedures. ZIFT has the advantages
of allowing fertilization to be confirmed and
it has demonstrated higher success rates
than IVF when used for the appropriate
indications.
 One disadvantage with ZIFT is that the
transfer of the zygote must be performed
through a laparoscope.

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Other techniques Cont’d
 GIFT
 Gamete intrafallopian transfer was developing
in 1984 as a variation of in vitro fertilization
(IVF).
 Gift is recommended when
 unexplained infertility
 infertility due to immunological factors
 endometriosis
 selected cases of male infertility
 Tubal infertility
 A requirement for the procedure is that the
female partner having at least one open
(patent) fallopian tube.

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Other techniques Cont’d
 TEST
 Tubal Embryo Transfer; the
placing of cleaving embryos into
the fallopian tube.
 POST
 Peritoneal Oocyte and Sperm
Transfer; the placement of oocytes
and sperm into the pelvic cavity

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Other techniques Cont’d
 ICSI
 Intracytoplasmic sperm injection, or ICSI,
was developed to treat couples who
previously had a very poor probability of
achieving fertilization due to the male
partner's extremely low numbers of viable
sperm.
 This treatment, when combined with in
vitro fertilization, allows these couples a
more favorable probability of achieving
conception.

Abdulkareem Sultan Al-Olama 34

Other techniques Cont’d
 TESE
 Testicular Sperm Extraction
 MESA
 Microsurgical Epididymal Sperm
Aspiration

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Counseling couple

 The use of skills that enable a client to

recognize and identify his (sic) own
problems, and the ability to help client find
his own solution or resolution.
 The Human Fertilization and Embryology
Authority (HFEA) state in their code of
practice that three sorts of counseling
must be available at licensed treatment
center. These are:
 Support counseling
 Implications counseling
 Therapeutic counseling

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Success rates
"take home baby rate"
 One of the first questions that most
people ask is "what is the chance for
success?" The best estimate is that the
birth of a live baby occurs in
approximately 15-25% of women in whom
embryos are transferred into the uterus.
 The 1998 nationwide live birth rate as
reported in the IVF-ET Registry, was
24.9%.
 The corresponding rate for 1989 was
14%.

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Success rates Cont’d
 Success varies with many factors,
including the number of embryos that are
transferred.
 If one embryo is transferred, there is
approximately a 7% chance of successful
implantation; with two embryos, the
success rate increases to 18%.
 The rate peaks with the transfer of three to
four embryos. Presently, the collection of
oocytes, fertilization, and early embryo
growth are accomplished with a high
degree of efficiency.

Abdulkareem Sultan Al-Olama 38

Success rates Cont’d
 The major hurdles to success are
implantation after embryo transfer and early
pregnancy loss. The rate of early pregnancy
loss is slightly, but not significantly, higher
with ART compared to spontaneous
conception.
 The risk of early pregnancy loss increases
with age of the female partner. Over age 40,
ART success rates decline dramatically.
 Pregnancy complications tend to be higher
with ART pregnancies, primarily because of
the much higher rate of multiple pregnancy.

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Success rates Cont’d
 Twins occur in about 25% of ART
pregnancies versus 1-2%of spontaneous
pregnancies. The risk of more than a
twin pregnancy is less than 5%.
 To put these figures into perspective,
studies have shown that the rate of
pregnancy in couples with proven fertility
in the past is approximately 20% per
cycle. Therefore, although a figure of 15-
25% may sound low, it is equal to or
greater than the chance that a fertile
couple will conceive in any given cycle.

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Cost effectiveness

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