Dr. ZEINAB ABOTALIB MRCOG, DGO, Consultant Obs/Gyna Infertility & IVF Assisted Conception Dr. ZEINAB ABOTALIB MRCOG, DGO, Associate Professor & Consultant Obs/Gyna Infertility & IVF

Assisted Conception IUI: intrauterine insemination IVF: in vitro fertilization ICSI: intracytoplasmic sperm injection GIFT: gamete intrafallopian transfer ZIFT: zygote intrafallopian transfer PESA: percutaneous epididymal sperm aspiration

Assisted Conception ET: embryo transfer TESE: testicular sperm extraction SUZI: subzonal sperm injection PGD: preimplantation genetic diagnosis

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

Assisted Conception Main types: IUI: intrauterine insemination IVF: in vitro fertilization ICSI: intracytoplasmic sperm injection

Assisted Conception Required procedures Superovulation Sperm preparation Assisted fertilization

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

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

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

Sperm Preparation Select PMNS 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

Intrauterine insemination Sperm sample deposited in uterus just before release of an oocyte (s) in a natural or stimulated cycle 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

Gamete intrafallopian transfer Laparoscopic technique in which oocyte and sperm placed in fallopian tube, allowing in vivo fertilization Procedure Superovulation US guided transvaginal oocyte retrieval 0.1-0.2 mil sperm with 2-3 oocytes

In vitro fertilization - IVF Taking oocytes from woman Fertilizing them in lab with her partner's sperm Transferring resulting embryos back to her uterus 3 or 5 days later

IVF Procedure Superovulation Insemination Embryo transfer Luteal support

IVF - Superovulation Gonadotropin stimulation Monitoring follicular development US guided transvaginal oocyte retrieval Oocyte fertilization with sperm

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

IVF - Insemination Syngamy (combination of maternal and paternal pronuclei 24 hrs after insemination Further cleavages occur at 24 hr intervals

IVF - Embryo transfer Embryos transferred to uterus on 2nd or 3rd day after in vitro insemination 4-8 cells embryos 2-3 embryos transferred in 20 µl of culture fluid Transabdominal US to see fluid placed in uterus Cryopreserve excess embryos

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

Intracytoplasmic sperm injection - ICSI Injection of single sperm into single oocyte in order to get fertilization Procedure Superovulation US guided transvaginal oocyte retrieval IVF Oocytes injected with sperm using special microscopes, needles and micromanipulation equipment

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

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

Assisted Hatching – Procedure Embryo held with a specialized holding pipette A needle used to expel an acidic solution against ZP A small hole made in ZP Embryo washed and put back in culture in incubator ET shortly after hatching procedure Hope for the best

Further Advances And Uses Of Assisted Conception Technology Cryopreservation of Sperm Embryo Oocyte Ovarian tissue Growth of human follicles and oocytes in vitro In vitro maturation and transplantation of human spermatozoa

Assisted Reproductive Technology (ART) Dr. Abdelsalam Talafha American Board Certified, Comparative Veterinary Obstetrics and Gynecology

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

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

ART USA women infertility rate Ages 20-24: 4.1% Ages 25-29: 5.5% 80% of infertility cases can be diagnosed 85% of cases can be successfully treated

ART Female infertility Disorders of ovulation: 27% Fallopian tube disorders: 22% Pelvic adhesions: 12% Endometriosis: 5% to 15% Hyperprolactinemia: 7%

ART Male infertility Abnormal semen parameters Count, motility, morphology Infertility treatment Correcting underlying abnormality ART

ART Main techniques IUI IVF - embryo transfer ICSI Assisted hatching

Preimplantation Genetic Diagnosis (PGD) Identify genetic conditions in embryo before ET Hemophilia Cystic fibrosis Aneuploidy

PGD Hemophilia Hereditary bleeding disorder Absence of a blood protein essential for clotting Types A: lack of factor VIII Type B: lack of factor IX

PGD Cystic fibrosis Genetic disease Defective gene causes body to produce abnormally thick, sticky mucus that obstruct Lungs Pancreas

PGD Aneuploidy Having less than or more than normal diploid number of chromosomes Monosomy Trisomy Triploidy

PGD Performed with IVF 8-cell stage (3 days old) embryo biopsy Obtain 1-2 blastomeres for genetic

Three day old embryos

PGD Genetic analysis Multicolor fluorescence in situ hybridization (FISH) Polymerase chain reaction (PCR)

FISH Detects Number of chromosomes Sexing embryos Sex chromosome aneuploidy Whole-chromosome paints for detection of rearrangements and identification of marker chromosomes Analyze polar bodies

FISH Fuorescent probes that bind to specific chromosomes are labeled with biotin for detection by specific fluorochrome-conjugated antibodies under a fluorescent microscope

Interphase nucleus X Y

Triploid Normal Diploid Tetraploid Missing chromosomes

PGD Double trisomy Monosomy