Assisted Conception Assisted Conception

Dr. ZEINAB ABOTALIB MRCOG, DGO,Dr. ZEINAB ABOTALIB MRCOG, DGO,Associate Professor & Associate Professor &

Consultant Obs/Gyna Infertility & IVFConsultant Obs/Gyna Infertility & IVF

Assisted ConceptionAssisted 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 ConceptionAssisted Conception

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

Assisted ConceptionAssisted Conception

• Objective– To bring sperm and oocyte close to each

other to promote chances of fertilization and, ultimately, achieve a pregnancy

Assisted ConceptionAssisted Conception

• Main types:– IUI: intrauterine insemination– IVF: in vitro fertilization – ICSI: intracytoplasmic sperm injection

Assisted ConceptionAssisted Conception

• Required procedures– Superovulation – Sperm preparation – Assisted fertilization

SuperovulationSuperovulation

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

SuperovulationSuperovulation

• 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- protocolSuperovulation- 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 PreparationSperm 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 inseminationIntrauterine 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 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 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

IVFIVF

• Procedure– Superovulation– Insemination– Embryo transfer – Luteal support

IVF - SuperovulationIVF - Superovulation

• Gonadotropin stimulation • Monitoring follicular development• US guided transvaginal oocyte retrieval• Oocyte fertilization with sperm

IVF - InseminationIVF - 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 - InseminationIVF - Insemination

• Syngamy (combination of maternal and paternal pronuclei 24 hrs after insemination

• Further cleavages occur at 24 hr intervals

IVF - Embryo transfer 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 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 - ICSIIntracytoplasmic 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 - IndicationsICSI - 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 HatchingAssisted Hatching

• Indications – Couples having IVF with

• Female partner's age over 37• Poor quality embryos

–Excessive fragmentation–Slow rates of cell division

Assisted Hatching – ProcedureAssisted 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 Further Advances And Uses Of Assisted Conception TechnologyConception 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)Assisted Reproductive Technology (ART)

Dr. Abdelsalam TalafhaDr. Abdelsalam Talafha

American Board Certified, Comparative American Board Certified, Comparative Veterinary Obstetrics and Gynecology Veterinary Obstetrics and Gynecology

ARTART

• 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

ARTART

• Infertility – Female partner: 35% – Male partner: 35% – Both partners: 20%– Unknown cause: 10%

• Infertility more common with increasing age

ARTART

• USA women infertility rate– Ages 20-24: 4.1%– Ages 25-29: 5.5%– Ages 30-34: 9.4%– Ages 35-39: 19.7%

• 80% of infertility cases can be diagnosed• 85% of cases can be successfully treated

ARTART

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

ARTART

• Male infertility– Abnormal semen parameters

• Count, motility, morphology • Infertility treatment

– Correcting underlying abnormality– ART

ARTART

• Main techniques– IUI– IVF - embryo transfer – ICSI– Assisted hatching

Preimplantation Genetic Diagnosis (PGD)Preimplantation Genetic Diagnosis (PGD)

• Identify genetic conditions in embryo before ET – Hemophilia– Cystic fibrosis– Aneuploidy

PGDPGD

• Hemophilia– Hereditary bleeding disorder– Absence of a blood protein essential for

clotting– Types A: lack of factor VIII– Type B: lack of factor IX

PGDPGD

• Cystic fibrosis– Genetic disease– Defective gene causes body to produce

abnormally thick, sticky mucus that obstruct • Lungs• Pancreas

PGDPGD

• Aneuploidy– Having less than or more than normal diploid

number of chromosomes• Monosomy• Trisomy • Triploidy

PGDPGD

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

Three day old embryos

PGDPGD

• Genetic analysis– Multicolor fluorescence in situ hybridization

(FISH) – Polymerase chain reaction (PCR)

FISHFISH

• Detects – Number of chromosomes – Sexing embryos – Sex chromosome aneuploidy – Whole-chromosome paints for detection of

rearrangements and identification of marker chromosomes

– Analyze polar bodies

FISHFISH

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

X

Y

Interphase nucleus

Normal DiploidTriploid

Tetraploid Missing chromosomes

Monosomy Double trisomy

PGDPGD