Infertility and ivf

Infertility and IVF

1. DR NILESH KATE MBBS,MD PROFESSOR ESIC MEDICAL COLLEGE, GULBARGA. DEPT. OF PHYSIOLOGY INFERTILITY & IVF

2. OBJECTIVES Infertility Definition Cause Diagnosis Treatment IVF Indication Steps Variations. Wednesday, June 17, 2020

3. Infertility. Def - Infertility refers to an inability to conceive after having regular unprotected sex. It is a significant social and medical problem affecting couples world wide. Average incidence --15% Unexplained infertility constitutes about 10 % of all cases. Wednesday, June 17, 2020

4. Definition. Infertility is the failure to achieve a birth ever a 12 months period of unprotected intercourse. Infertility is the inability of a sexually active non contracepting couple to achieve pregnancy in one year. Wednesday, June 17, 2020

5. Defect. Wednesday, June 17, 2020

6. Causes of infertility in men Low sperm count: Less than 10 million sperm per ml of semen. Normal count is 35 million sperm per ml of semen or more. No sperm: - Absence of sperms in semen. Wednesday, June 17, 2020

7. Causes of infertility in men Low sperm motility: Sperms are immotile, can not swim. Abnormal sperms: (Unusual shape , more difficult to move and fertilize egg ) Its causes are: Testicular infections. Testicular cancer. Testicular surgery. Wednesday, June 17, 2020

8. Other causes. Hypogonadism (testosterone deficiency). Genetic abnormality. Mumps (testicular inflammation). Hypospadiasis. Chlamydia infection Ejaculation disorders (Retrograde ejaculation). Variocele (includes varicose vein in scrotum). Undescended testicles. Overheating testicles. Wednesday, June 17, 2020

9. Causes of infertility in women. Ovulation disorders: Premature ovarian failure (before age of 40) Polycystic ovary syndrome. Hyper- prolactinemia (in non pregnant state) Poor egg quality. Wednesday, June 17, 2020

10. Causes of infertility in women. Defect in uterus & fallopian tubes: Surgery. Sub-mucosal fibroids. Endometriosis. Previous sterilization treatment Wednesday, June 17, 2020

11. Causes of infertility in women. Drugs : NSAID’S (aspirin & ibuprofen). Chemotherapy. Radiotherapy. Illegal drugs. Wednesday, June 17, 2020

12. Types. Wednesday, June 17, 2020

13. Diagnosis. Wednesday, June 17, 2020

14. Treatment. In males In females. Wednesday, June 17, 2020

15. Treatment in males. Blockage of the ejaculatory duct Sperms can be extracted directly from the testicles and injected into an egg in laboratory. Wednesday, June 17, 2020

16. Surgery for epididymal blockage A bypass of the blockage can be performed, called vaso-epididymostomy (vas deferens is re-connected to epididymis ). Wednesday, June 17, 2020

17. Retrograde ejaculation Sperms can be taken directly from the bladder and injected into an egg in laboratory. Wednesday, June 17, 2020

18. Others. Premature ejaculation or Erectile dysfunction Behavioral approaches (giving suggestions) or medications. Variocele If there is varicose vein in scrotum, it can be surgically removed. Wednesday, June 17, 2020

19. Treatment in females. Wednesday, June 17, 2020

20. Treatment in females. Wednesday, June 17, 2020

21. COUNSELING Deals with the psychosocial impact of infertility in terms of : Intervention, Treatment, and After-effects of both successful and unsuccessful treatments. Wednesday, June 17, 2020

22. COUNSELING It also involves therapeutic work to help patient cope with the consequences of infertility & treatment. Wednesday, June 17, 2020

23. Objectives of counseling. Informed consent. To offer coping strategies to couples. To facilitate decision making. To offer preparation for procedures. To help client in achieving a better quality of life. To provide genetic counseling . Wednesday, June 17, 2020

24. Advantages Helps to deal with the emotional stress. Provide extra support. Allow the client in exploring all possible options for family. Wednesday, June 17, 2020

25. Advantages…… Help the couples in overcoming the dilemmas & deciding the right fertility treatment. Explains about the infertility management & specific treatment. Wednesday, June 17, 2020

26. ASSISTED REPRODUCTION TECNOLOGY (ART) - ETHICAL & LEGAL ASPECT Aim – Is to promote the chances of fertilization and Subsequent pregnancy by bringing the sperm and egg close to each other. Wednesday, June 17, 2020

27. Invitro – fertilization. Is a process by which an egg is fertilised by sperm outside the body: in vitro. Babies conceived as the result of IVF, are called “ Test tube babies” . Wednesday, June 17, 2020

28. History. Wednesday, June 17, 2020

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30. Indian history. Dr. Subhash Mukhopadhyay (16 January 1931 – 19 June 1981) was a physician from Kolkata, India, who created the world's second and India's first child using in-vitro fertilisation , Durga who was born 67 days after the first IVF baby in United Kingdom. Wednesday, June 17, 2020

31. Indications. Tubal disease. In women with blocked fallopian tubes, IVF has largely replaced surgery as the treatment of choice. Endometriosis. Patients with endometriosis, often have tubal involvement and ovarian cysts (endometrioma). Ovulatory dysfunction. In patients with polycystic ovarian disease (PCOS) and other ovulatory problems. Wednesday, June 17, 2020

32. Indications. Age Related Infertility. In normal reproductive life, a woman's ovarian function is diminished with age. In many cases, this reduced function can be overcome through the use of IVF Male Factor Infertility. Azoospermia, oligozoospermia , asthenozoospermia , anti-sperm antibody. Preimplantation Genetic Testing (PGT). Genetic testing on preimplantation embryos may be indicated for patients who are at risk for genetic disorders such as Cystic fibrosis and Thalassemia Wednesday, June 17, 2020

33. Process. Initial evaluation Suppression of natural hormonal cycle Ovarian stimulation Collection of oocytes Collection of sperms In vitro fertilization of oocytes Embryo transfer Wednesday, June 17, 2020

34. Initial evaluation Blood tests Seminal Fluid examination Hysterosalpingogram Trans vaginal ultrasound Wednesday, June 17, 2020

35. Suppression of natural hormonal cycle Oral contraceptive pills – each day starting cycle day 1, 2 or 3 for approximately 2-4 weeks Lupron / Leuprolide Acetate – GnRH Agonists. It suppresses LH surge preventing eggs from being released before they are mature for egg retrieval. Subcutaneous inj every morning Nafarelin - GnRH Agonists, three times a day nasal spray. Ganirelix Acetate Injection / Cetrotide – GnRH antagonists Wednesday, June 17, 2020

36. Ovarian stimulation Produce multiple mature follicles, rather than the single egg normally developed each month. Produces many good follicles to be Fertilized. Multiple eggs are stimulated because some eggs will not fertilize or develop normally after fertilization. Regular monitoring by ultrasound scan is done. Wednesday, June 17, 2020

37. Collection of oocytes The oocyte maturation is performed, generally by an injection of human chorionic gonadotropin (hCG). Commonly, known as the "trigger shot.“ The egg retrieval is performed at a time usually between 34 and 36 hours after hCG injection. Egg retrieval is usually accomplished by transvaginal ultrasound aspiration. Wednesday, June 17, 2020

38. Collection of oocytes It is done under short general anesthesia, and is 20 to 30 minutes procedure. In some circumstances, one or both ovaries may not be accessible by transvaginal ultrasound. Laparoscopy may then be used to retrieve the eggs using a small telescope placed in the umbilicus. Wednesday, June 17, 2020

39. Collection of sperms Shortly before or after the oocyte collection the male partner will be asked to give a sperm sample. Sexual abstinence of 3-4 days should b exercised. Collected about 60-90 minutes prior to fertilization,. Wednesday, June 17, 2020

40. Collection of sperms Liquefied ,centrifuged, suspended in culture medium, and incubated for 30-60 mins at 37⁰ C. The most active sperms are located in the surface of the medium. Sperm may be obtained from the testicle, epididymis, or vas deferens from men whose semen is void of sperm either due to an obstruction. Wednesday, June 17, 2020

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42. In vitro fertilization of oocytes Fertilization is started by adding 10,000-50,000 motile sperms to about 100 μl to 1 ml culture medium in which the oocytes is being incubated. Intra-cytoplasmic sperm injection (ICSI) is indicated in cases where semen fluid does not contain sperm. Wednesday, June 17, 2020

43. Types. Intra-uterine Insemination (IUI) In- vitro fertilization (IVF)/ Embryo transfer Intracytoplasmic sperm injection (ICSI) Gamete intra-fallopian transfer (GIFT) & Zygote intra-fallopian transfer (ZIFT) Wednesday, June 17, 2020

44. Intra-uterine Insemination(IUI) First line Indications Hostile cervical mucus Anti-sperm or male fertility problem (low sperm count or premature ejaculation) Although tubal patency of female partner must be assured Wednesday, June 17, 2020

45. In- vitro fertilization (IVF)/ Embryo transfer Fertilization occurs outside the body. Indications Uterine tube occlusion Endometriosis or cervical mucus problems, where male factors are main problem Wednesday, June 17, 2020

46. Intracytoplasmic sperm injection (ICSI) The injection of a single sperm into the cytoplasm of an egg with a fine glass needle. Useful technique when sperm quality is poor. In azoospermic man sperm can be obtained surgically from the epididymis or by extraction from testis itself. Wednesday, June 17, 2020

47. Intra-cytoplasmic sperm injection (ICSI) An embryologist isolates a sperm cell, draws it up into a microscopic needle and injects it inside an oocyte using a high power microscope. Fertilisation check is performed the next day Wednesday, June 17, 2020

48. Intra-cytoplasmic sperm injection (ICSI) Approximately 18 hours after sperm injection or insemination of the eggs. Usually 65% to 75% of mature eggs will fertilize after insemination Wednesday, June 17, 2020

49. Intra-cytoplasmic sperm injection (ICSI) They are cultured in special incubators to support division and development. If the couple has a history of certain genetic disease and the gene that is causing that problem is identified, a pre-implantation genetic diagnosis may be done. Wednesday, June 17, 2020

50. Embryo transfer Performed on day 2, 3 or 5 post fertilization. One or more embryos suspended in a drop of culture medium are drawn into a transfer catheter, a long, thin sterile tube with a syringe on one end. Wednesday, June 17, 2020

51. Embryo transfer The physician gently guides the tip of the transfer catheter through the cervix and places the fluid containing the embryos into the uterine cavity Wednesday, June 17, 2020

52. Embryo transfer Related to age and embryo quality o <35 = 2 o 35-37 = 2-3 o 38-40 = 3-4 o >40 = up to 5 For patients with 2 or more failed IVF cycles, or a poor prognosis, can add more based on clinical judgement Wednesday, June 17, 2020

53. Variations of IVF Gamete intrafallopian transfer (GIFT) Zygote intrafallopian transfer (ZIFT). Wednesday, June 17, 2020

54. Gamete intra-fallopian transfer (GIFT) & Zygote intra-fallopian transfer (ZIFT) Laparoscopic technique that offer little clinical advantage over invitro fertilization (IVF) Wednesday, June 17, 2020

55. THANK YOU