1. ART Assisted reproductive technology Dithawut Khrutmuang MD.

2. Assisted reproductive technology All treatments or procedures which include the handling of human oocytes or embryos, including in vitro fertilization, gamete intrafallopian transfer, zygote intrsifallopian transfer, and such other specific technologies as the Secretary may include in this definition. 1992 Fertility Clinic Success Rate and Certification Act

3. Assisted Reproductive Technology (ART) In vitro fertilization-embryo transfer (IVF-ET)/intracytoplasmic sperm injection (ICSI) Gamete intrafallopian transfer (GIFT)/ Zygote intrafallopian transfer (ZIFT) Frozen embryo transfer (FET). ART may be recommended when other treatments (such as intrauterine insemination) have not been successful or when there is severe male factor infertility, severe endometriosis or tubal obstruction. 2011 the American Society for Reproductive Medicine

4. Evaluation before ART General Before starting ART, each patient is evaluated to help maximize her chances for success and a healthy pregnancy. Chronic medical conditions such as diabetes, hypertension and asthma should be well controlled before attempting to conceive. Women planning an IVF cycle should optimize their weight. Obesity has been associated with infertility, a reduced chance of success with IVF, and an increase in the risk of miscarriage and preterm birth. 2011 the American Society for Reproductive Medicine

5. Ovarian reserve test J Hum Reprod Sci. 2011 Sep-Dec; 4(3): 108–113.

6. Evaluation before ART Uterus The uterus is usually evaluated prior to an IVF. Three methods can be used: HSG, SIS or hysteroscopy. Prior to IVF, a trial or “mock” transfer may be done. The purpose of this procedure is to determine the length and direction of the uterus. Semen A semen analysis should be reviewed. Changes in sperm quality may occur over time that could affect IVF success. 2011 the American Society for Reproductive Medicine

7. Prerequisite test before ART Female HIV Hepatitis B antigen Hepatitis C antibody VDRL/RPR Pap smear Blood group, Rh, and antibody screen Male HIV Hepatitis B antigen Hepatitis C antibody VDRL/RPR Complex semen analysis, antisperm antibodies, and strict morphology 2011 the American Society for Reproductive Medicine

8. STRONGLY RECOMMENDED PRENATAL TESTS Female Rubella titer Varicella titer Hemoglobin electrophoresis Cervical swab for Gonorrhea and Chlamydia Male Hemoglobin electrophoresis 2011 the American Society for Reproductive Medicine

9. ART Cycle Pre-stimulation treatment Ovarian stimulation with gonadotropins Monitoring follicle development Final oocytes maturation Transvaginal oocyte retrieval Insemination Embryo transfer Progesterone supplementation Pregnancy test Early pregnancy follow-up 2011 the American Society for Reproductive Medicine

10. Ovarian stimulation with gonadotropins Santos M A et al. 2010;139:23-34 ©2009 by Society for Reproduction and Fertility

11. Ovulation induction VS. Controlled ovarian hyperstimulation Ovulation induction Use in anovulatory infertility. Restore physiologic of cyclic ovarian function. Aim : Ovulation of single follicle Controlled ovarian hyperstimulation Superovulation Stimulation of multiple follicular development Aim : multiple follicular development for ART 2011 the American Society for Reproductive Medicine

12. Controlled ovarian hyperstimulation Long agonistAntagonist Merck & Co., Inc

13. GnRH agonist / antagonist used to inhibit a premature LH surge

14. GnRH Agonists Gonadotropin releasing hormone (GnRH) is a hormone produced in the brain that indirectly stimulates ovarian function. Agonists of GnRH are synthetic forms of this hormone Mechanism Of Action Agonists of GnRH initially stimulate the pituitary gland to release all the stored gonadotropins (LH and FSH -the hormones that normally stimulate ovarian function). Over the course of a week to 10 days, GnRH analogs suppress the production of any new LH and FSH. This effect appears to prevent the ovaries from receiving mixed signals from the patient's own LH and FSH and from the medications that are administered to stimulate follicle development. The result for many patients is a more synchronized development of mature oocytes. 2011 the American Society for Reproductive Medicine

15. GnRH agonist protocol Route of administration Days of cycle ( CD)Duration administration UltrashortNS / SC2,3 – 4,53 days ShortNS / SC2,3 until day of hCG8 -12 days Menstrual early cessationNS / SC21 until menses7 -12 days Follicular early cessationNS / SC21 until stimulate D6,713 -20 days Long follicularNS / SC2 until day of hCG28 -35 days Long follicular(depot)Depot2Once Long lutealNS / SC21 until day of hCG21 -28 days Long luteal(depot)Depot21Once UltralongNS / SC / Depot2 or 218-12 weeks, depot 2-3 times

16. GnRH agonist protocolAdvantasgeDisadvantage UltrashortPatient’s comfort, Poor respondersLow PR, Low oocyte quality No programming ShortPatient’s comfort, Poor respondersLow PR, Low oocyte quality No programming Menstrual early cessationInconclusiveLow E2 level, high cancel rate Follicular early cessationInconclusiveLow E2 level, high cancel rate Long follicularGood PR, High number oocytes, programmingLong duration Long follicular(depot)Patient’s comfortToo long duration of action Long lutealGood PR, programmingLong duration Long luteal(depot)Patient’s comfortToo long duration of action UltralongEndometriosis Sideeffects due to estrogen deficiency

17. GNRH Antagonists Antagonists of GnRH are directly and immediately inhibit FSH and LH production. Ultrasound measurements of follicular growth are used to determine when to start these medicines. Mechanism of Action GnRH antagonists bind to the receptor for gonoadotropin releasing hormone on the pituitary, preventing the natural luteinizing hormone surge and ovulation. 2011 the American Society for Reproductive Medicine

18. GnRH antagonist protocols

19. Complex heterodimeric glycoproteins 2 non-covalent linked proteins: α - subunit: β - subunit: unique, specific hormonal function Gonadotropins ; use in ovarian stimulation

20. Pregnant mare serum Pig pituitary gland extracts Human menopausal gonadotropin (hMG) Recombinant human gonadotropins Exogenous gonadotropins

21. Corifollitropin alfa ;New long-acting gonadotropins

22. A heterodimeric glycoproteins Bind to receptor on the theca cells and granulosa cells (late follicular phase) Main role: Stimulate androgen production from the theca cells Triggering ovulation Supporting the corpus luteum Indication: Hypogonadotropic hypogonadism Profound pituitary & ovarian desensitization (GnRH agonist) Poor responder, age > 35 years Luteinzing hormone

23. Predict the ovarian response to gonadotropins. Monitor effect of pituitary down-regulation. Evaluate whether the dose of gonadotropin is adequate. Avoid OHSS Find the optimal time to give hCG COH monitoring : Why ? 2011 the American Society for Reproductive Medicine

24. Trigger ovulation; When? 3 follicles of 18 mm (mean of 2 diameters) on Day 9 -10 of stimulation and fewer than 15 follicles and Endometrial thickness : ≥ 7 mm. Drug used to trigger ovulation Urinary human chorionic gonadotrophin (uhCG) Recombinant hCG (rhCG) Recombinant LH (rLH) GnRH agonist Final oocytes maturation / trigger ovulation

25. Merck & Co., Inc

28. Success rate Success varies with many factors. Age of the woman is the most important factor Quality of embryos Number of embryos transferred J Hum Reprod Sci. 2011 Sep-Dec; 4(3): 108–113.

29. Success rate Fresh Embryos From Non-Donor Oocytes 2014 SART