1Artificial / Assisted Reproductive Techniques (ART) Dr Sohani VermaSr. Consultant Obstetrics & GynaecologyInfertility & ART SpecialistClinical & Academic CoordinatorIndraprastha Apollo Hospitals, New DelhiChairperson North Zone AICC RCOGPresident Elect Indian Fertility Society
2IntroductionA woman of reproductive age who has not conceived after 1 year of unprotected vaginal sexual intercourse, in the absence of any known cause of infertility, should be offered further clinical assessment and investigation along with her partner.Offer an earlier referral for specialist consultation to discuss the options for attempting conception, further assessment and appropriate treatment where –- the woman is aged 36 years or over- there is a known clinical cause of infertility or a history of predisposing factors for infertilityNICE Guidelines 2013
3Main Causes of Infertility Multiple relatively minor abnormalities, either with 1 partner or both, account for 30% of all causes
4Assisted Reproductive Techniques (ART) Any treatment that deals with “means of conception other than vaginal intercourse” is termed as ART.NICE guideline 2013IUI – Intra Uterine Insemination (Husband / Donor)IVF + ET – In Vitro Fertilization + Embryo transferICSI – Intra Cytoplasmic Sperm Injection
5IUI Injection of washed prepared sperms into the uterine cavity through a fine catheterduring peri-ovulatory phase in a naturalor stimulated cycle.Although pregnancy may not occur as quickly, a policy of initial treatment by IUI will probably save 20% of couples from moving onto IVFAfter 3-4 cycles of failed IUI treatment, patients should be encouraged to opt for IVF
6IUIThe procedure may help in increasing the chances of pregnancy in following ways –Allowing sperm-ovum contact close to the date and time of ovulationBy bringing the sperm very close to the site of fertilization and by passing the cervical factorsSperm preparation increases the sperm density and removes all antigens on the surface of sperm and in seminal plasmaIUI is the simplest and the least expensive method of ARTIUI alone (natural cycle) does not improve pregnancy chances, hence mild ovarian stimulation is usually recommended.
7Indications for Intra Uterine Insemination (IUI) - At least one Fallopian tube must be normal and patent Mild male infertility Unexplained infertility Ovulatory dysfunction, PCOS Mild endometriosis Cervical factors Coital problems Immunological factors HIV, HBs Ag infection Donor Sperm
8Indications for Donor Sperm IUI Azoospermia (where ICSI is not an option)Severely subnormal semen parameters (ICSI not an option)Persistent failure of ICSIRh IsoimmunizationHereditary disease in the male partners
9Indication for ART – IUI or IVF The indications for IUI are often not dissimilar to those for IVF (or even for ICSI for moderate male factor) and often interchangeable with overlapping.
10Common Indications for IUI Indications for IVF Unexplained infertility - Unexplained infertilityEndometriosis (mild) - Endometriosis (moderate to severe)Male factor infertility (mild) Male factor infertility (moderate to severe)Ovulatory disorders Ovulatory disordersInability to have vaginal intercoursePeople with conditions that require Tubal pathologyspecific consideration (such as man HIV - Donor Oocytepositive) Genetic Surrogacy- People in same-sex relationship PGD (Possibility of genetically- Donor Sperm transmitted disease) Fertility preservation in cancer patients- Where ICSI is indicated (Azoospermia)
11Meta-Analysis of IUI in Male Factor Pregnancy RateTimed intercourse in natural cycle 2.4%Timed intercourse in COH cycle 5.0%IUI in natural cycle %IUI in COH cycles %Cohlen BJ et al Cochrane database Syst Rev 2003
12Basic requirements for IUI success Patient selectionAge of female partner < 35 yearsDuration of infertility < 5 yearsCause of infertility (at least one functional normalfallopian tube and no uterine factors)Adequate ovarian reserve (based on Serum AMH, antralfollicle count, Day 2 FSH, LH, E2 levels)Semen parameters Post wash TMSC >5 million/mlBest pregnancy rates with >10 million/ml< 1 or 2 million/ml – do not waste time in IUI. Advice IVF / ICSI straight away
13Basic requirements for IUI success contd… Choice of ovarian stimulation usedNumber of dominant follicles – 1 to 3 folliclesUse of “transvaginal ultrasound follicle monitoring”Timing of IUIBetween day 12 to 16 of the cycle usually highest pregnancy ratesInterval from hCG injection Hours usually recommended (range hours)Single IUI 36 hours after hCG is usually the preferred option.
14Basic requirements for IUI success contd… Semen preparation technique – Quality and expertize of lab personnelProcedure of IUI & type of catheter usedLuteal support is recommendedHow many IUI cycles- 3-6 cycles usually recommended
15INTRAUTERINE INSEMINATION – ESHRE Guidelines There is general agreement in the literature that chances of success are better after mild ovarian stimulation and the maturation of a maximum of two or three follicles.However, the cycle must be monitored by ultrasound and hormonal analysis; if there are more than three mature follicles, the attempt should be cancelled.While the concurrent use of ovarian stimulation may increase pregnancy rates, it may be at the expense of a high chance of multiple pregnancy.The majority of pregnancies occur during the first six cycles. In any case, the number of attempts should not exceed nine cycles.When assessing the duration of an IUI programme, the age of the woman must be taken into account, to ensure timely transfer to more complex treatments if indicated.
16The world's first "test-tube baby", Louise Brown, has spoken of her joy at giving birth to her first child.Baby Cameron was born on 20 December’06 in Bristol, where his 28-year-old mother lives with husband Wesley Mullinder.Well over two million "test-tube" babies have been born globally since Louise's 1978 birth after IVF
17IVF and ETIn Vitro Fertilization (IVF) and Embryo Transfer (ET) are the basic ART for all related technology. These include:- Intra Cytoplasmic Sperm Injection (ICSI)- Assisted hatching- Pre-implantation Genetic Diagnosis (PGD)- Cryopreservation- Donor oocyte IVF programs- Donor embryo (genetic surrogacy)- Intracytoplasmic Morphologically selectedSperm Injection (IMSI)- And many more
18Various steps of an IVF treatment cycle Pre IVF work-upOvarian stimulationMonitoringOvulation inductionPreparation of spermsOocyte retrievalIn Vitro FertilizationEmbryo transferLuteal Support
20In vitro embryo development COC at the time of retrievalM II oocyte with a PB (Mature)2 PN embryo4 cell embryo8 cell embryoFully grown blastocyst
21Indication for IVF I. IVF as first line infertility treatment Tubal pathology (severe, non-repairable)Donor OocyteGenetic SurrogacyPGD (Possibility of genetically transmitted disease)Fertility preservation in cancer patientsWhere ICSI is indicated (Azoospermia)II. IVF following failed cycles of IUIUsually up to six cycles of IUI with controlled ovarian stimulation are recommended, but there are situations where couples should move to IVF earlier.
22Indicators for early referral I. Female age - The biological clock is the major adversary to human reproduction
23Woman’s age is the initial predictor of her overall chance of success Live birth rates per Embryo transfer by age (HFEA post-October 2007 data)NICE Guideline 2013
24II. Diminished Ovarian Reserve at any age - AMH- anti-Mullerian hormone of less than or equal to pmol/lAntral Follicle Count (AFC) – Less than or equal to 4Day 2/3 FSH >8.9 IU/LEndometriosisModerate (more than slightly abnormal) degree of semen quality abnormalities.V. Tubal CompromiseNICE Guideline 2013
25ICSIUnprecedented successful development of ART which has revolutionized the management of severe male infertility (Van Steirte-ghen 1992)The procedure involves the direct injection of a single sperm into the egg cytoplasm
26Indications for ICSI Severe alterations of semen characteristics History of fertilization failure in conventional IVF attemptsTesticular or epidydimal spermOther relative indications
27Success rates following IVF / ICSI 24.7 percent clinical pregnancies of all women who undergo IVF treatment (HFEA 2011).50% of all embryos cultured in vitro reach blastocysts stage by day 6.About 15% of transferred embryos will develop into a baby
28Basics requirements for IVF/ICSI success Pre – IVF work up of the infertile coupleClinical historyExaminationInvestigationsCounselingWhy necessary?To identify the cause of infertility and thereby prognosisTo identify and correct associated adverse factors before treatingprimary disorderTo decide most appropriate treatment protocol Type of drug starting dosage expected response and problemsTo assess reproductive ageing and plan early access / resort to ART treatments
29Basic requirements for IVF/ICSI success contd… 2. To get adequate number of good quality oocytesPredictors of COHS response Normal responders Hyper responders Hypo- responders Age, AMH, AFC- Response to earlier COHS- Basal FSH, LH, E2- BMI, Smoking, Alcohol Previous Ovarian Surgery B. Selection of COHS protocol Agonist versus Antagonist protocols Mild stimulation protocols
30Basic requirements for IVF/ICSI success contd… C. Ultrasound monitoring with power and colourDopplerD. Biochemical MonitoringOvulation induction hCG - urinary / recombinant GnRh agonistTechnique of Oocyte retrievalEmbryology lab quality and expertizeIVF or ICSISelecting best embryo (s) for transferNumber of embryos transferredEmbryo transfer techniqueLuteal Support
32Luteal SupportThe transformation of mature follicle into corpus Luteum (CL) after the release of ovum is triggered by an optimal LH surge.The function of CL is dependent upon continued LH stimulation in luteal phase.CL is an essential source of pro-fertility hormones ie Progesterone (P), Estrogen (E) and other vasoactive and growth factors.
33Luteal SupportIt is well established that the ovarian stimulation regimens used in assisted reproduction cycles alter the luteal phase.Edwards et al 1980, Kolibianakis et al 2003Ovarian stimulation causesan inadequate development of the endometriuman asynchrony between the endometrium and the transferred embryo andadverse effects on endometrial receptivityMacklon & Fraser 2000, Devroey et al 2004
34Luteal Support contd…The luteal phase defect in IVF is present whether GnRH agonist or antagonist is used (Friedlers et al 2006).The possible mechanism responsible may be –Continuation of pituitary down regulation effectDuration of luteal phase is shortenedFormation of multiple CL leading to inhibition of pulsatile LH releaseLoss of granulosa cells during oocyte retrieval
35Luteal Phase SupportEndometrial support – complements production by CLProgesterone preparationEstrogen preparationAgents which support CLhCGGnRH-analogueLHNewer agents which promote angiogenesis andvascular supply
37Estrogen as an adjuvant to LPS Estradiol valerate. HemihydrateOral (intravaginal)2-6 mg/dayMicronized EstradiolOral or intravaginalTransdermal EstradiolPatches (2 per week)ugm/day
38GnRH agonist as an adjuvent to LPS Luteal Phase Support for assisted reproduction cycles (Cochrane Review 2011)Tesarik J et al 2006 published their result on 600 women randomly assigned to receive a single injection of GnRH agonist (0.1 mg of triptorelin) or placebo on Day 6 after ICSI. The results showed improvement of implantation and live birth rates.Van der Linder et al investigated progesterone versus prog + GnRHagonistSix studies (1646 women)There were significant results showing a benefit from addition to GnRH agonist to progesterone for the outcomes of live birth, clinical pregnancy and ongoing pregnancy.
39Luteal Phase Support for ART Cycles Authors' conclusionsCochrane review 2011 showed a significant effect in favour of progesterone for luteal phase support, favouring synthetic progesterone over micronized progesterone. Overall, the addition of other substances such as estrogen or hCG did not seem to improve outcomes.They found no evidence favouring a specific route or duration of administration of progesterone.It was found that hCG, or hCG plus progesterone, was associated with a higher risk of OHSS.The use of hCG should therefore be avoided.There were significant results showing a benefit from addition of GnRH agonist to progesterone for the outcomes of live birth, clinical pregnancy and on-going pregnancy.For now, progesterone seems to be the best option as luteal phase support, with better pregnancy results when synthetic progesterone is used.Cochrane Review 2011
40Nutritional Supplements and ART outcome No definite conclusive evidenceAnti-oxidants – Vit C, E, selenium, zinc, taurine, carotene, lycopeneVitamins – Folate, Vit B 12Myoinositol and D-chiro-inositol (vit B complex)L – ArginineDHEA
41Dehydroepiandrosterone (DHEA) supplementation Cason and associates (2000) were first to suggest therapeutic benefits from the supplementation of DHEA in women with diminished ovarian reserve and suggested it may improve oocyte yields via IGF-1.It was left to a 43 year old infertility patient in US (advised donor oocytes) to discover their paper and self administer DHEA while undergoing subsequent IVF cycles.The patient underwent nine consecutive IVF cycles and increased oocytes and embryo yields from cycle to cycle, starting with one egg and embryo, respectively, and ending up with 17 oocytes and 16 embryos in her ninth cycle.(Gleicher et al 2009)
42Dehydroepiandrosterone (DHEA) supplementation While all other pharmacological agents affect follicle maturation only during the final stage – gonadotropin – sensitive last 2 weeks, DHEA in contrast appears to affect folliculogenesis at much earlier stages of in-vivo follicle maturation (Gleicher N etal 2011)DHEA has been shown to increase the number of primary, preantral and antral follicles.DHEA supplementation is reported to improve ovarian response, IVF parameters and pregnancy chances. Younger patients with POA appears to have a slight pregnancy advantage.
43Cumulative pregnancy rates in women with DOR with and without DHEA supplementation. POA patients appear to have a slight pregnancy advantage, Barad et al 2007
44DHEA supplementation is also shown to significantly (50-80%) reduce the miscarriage risks in patients with poor ovarian reserve (Gleicher etal 2007)Age-stratified miscarriage rates in DHEA supplemented DOR patient in comparison to national U.S. IVF pregnancies. Gleicher et al 2009
45Treatment protocols, side effects and complications Micronized DHEA at a dosage of 25mg TIDEffects occur relatively quickly (6-8 weeks) but peak only after 5-6 months of supplementation.Side effects are small and rare and primarily relate to androgen effects – oily skin, acne vulgaris and hair loss.Even long-term therapy of DHEA in suggested dosages have been demonstrated safe (Panjari M etal 2009).However, before declaring DHEA as a wonder drug, larger RCTs are urgently needed to confirm the benefits.