1. New Developments in Assisted Reproduction
Cork Fertility Centre
Dr John Waterstone

2. Ovarian Reserve
Women are very different to men with regard to reproductive ageing.
A woman’s entire lifetime’s supply of eggs is present at birth.
Decreasing ovarian reserve is inevitable with increasing age, resulting in complete infertility by age
Decreasing ovarian reserve has a significant negative effect on a couple’s reproductive prospects from age 37 onwards but earlier for some women.
Ovarian reserve is a measure of how well the ovaries are still functioning at a certain point in time.

3. Measures of Ovarian Reserve
FSH (Follicle Stimulating Hormone)
- lower is better (Normal <10 iu/L)
test cycle day 2-4
fluctuates between cycles when ovarian reserve poor
AMH (Anti Mullerian Hormone)
higher is better (normal>5pmol/L)
less fluctuation between cycles

4. Measures of Ovarian Reserve
Antral Follicle Count (AFC)
higher is better
5-10 AF’s per ovary –normal reserve
<3 AF’s per ovary –poor reserve
>10-15 AF’s per ovary – ‘polycystic’
Menstrual cycle length
– shortening cycles indicate deteriorating ovarian reserve

7. Polycystic Ovaries & PCOS
Most women with polycystic ovaries do not have polycystic ovary syndrome
PCOS = PCOD = Stein Levinthal Syndrome
PCOS = Polycystic Ovaries + Oligo or Amenorrhoea
Variable abnormalities in PCOS
Raised LH
Raised Androgens
Hirsutism
Obesity
Impaired Glucose Tolerance

8. Management of PCOS
Good ovarian reserve but may be difficult to manage.
May succeed on first cycle of OII with Clomid
May undergo OII, IUI, Ovarian drilling, IVF
IVF also difficult because of risk of Ovarian Hyperstimulation Syndrome (OHSS)
Metformin –no longer recommended for OII nor as an adjunct to IVF; may help patients lose weight.

9. Tests of Tubal Function
Laparoscopy
- Gold standard test
- Carried out at Bon Secours Hospital
Detects adhesions /endometriosis
Hystero Salpingography (HSG)
- Less invasive
- Carried out Bon Secours Hospital
Does not detect adhesions/endometriosis
Hystero Contrast Salpingography (HyCoSy)
- Poor diagnostic test
- No longer used at Cork Fertility Centre

10. Pre-IVF Surgery for Hydrosalpinges
Communicating hydrosalpinges must be removed or blocked proximally prior to IVF

11. Tertiary Care – AR Options
Ovulation Induction (Clomid or low dose FSH)
IUI (low dose FSH)
IVF / ICSI (LHRH analogue, high dose FSH injections, egg collection, embryo transfer)

13. Embryo Transfer

14. Intracytoplasmic sperm injection (ICSI)
~ 40% of IVF cycles involve insemination by ICSI

15. TESE
ICSI/TESE appropriate for primary azoospermia and post vasectomy

16. Day 2 - Day 3 Embryo Development

17. Day 5 Embryo development

18. Day 5 Embryo Transfer Advantages Embryo Selection
Reduction in number of embryos for ET resulting in reduction in multiple gestations

19. Egg Donation For patients with poor ovarian reserve
Alternative to adoption or childlessness
Success Rate ~ 50% per cycle
Known v Anonymous Donors
Remuneration of Donors (Europe v USA)
Reproductive Tourism

20. Egg Donation at Cork Fertility Centre
Egg Donation available since 2006
Donors almost all known to recipient couple
Live Birth Rate (per embryo transfer) for 2006 – 2010: 61%

21. Cryopreservation of Gametes & Embryos
Cryopreservation of semen – successful & robust
Cryopreservation of viable embryos – technically easy
Cryopreservation of unfertilised eggs technically difficult but useful for:
creating donor egg banks
preserving fertility in young cancer survivors
preserving fertility in women deferring reproduction

22. CFC IVF/ICSI Success Rates 2010
Live birth rates per Embryo Transfer
Patient Age
<35
35-37
38-40
41-42
>42
Cork Fertility Centre 2010
49%
46%
35%
22%
8.5%
Success Rates” which quote “pregnancies” or “pregnancy rates” are misleading as a significant proportion of early pregnancies miscarry