fertility diagnosis and therapy 2008 gad lavy, m.d. new england fertility institute lifeline...
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Fertility Diagnosis Fertility Diagnosis and Therapy 2008and Therapy 2008
Gad Lavy, M.D.Gad Lavy, M.D.New England Fertility InstituteNew England Fertility Institute
Lifeline CryogenicsLifeline Cryogenics
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The New Technology and the The New Technology and the Aging OvaryAging Ovary
Improvement in diagnosis and therapyImprovement in diagnosis and therapy Aging and its impact on fertilityAging and its impact on fertility The Approach to the “older infertile couple”The Approach to the “older infertile couple”
More aggressive diagnostic and therapeutic More aggressive diagnostic and therapeutic approachapproach
ART ART IVFIVF PGDPGD Egg donationEgg donation Freezing of embryos, eggs and ovarian tissueFreezing of embryos, eggs and ovarian tissue
Team approach to fertility therapyTeam approach to fertility therapy
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Infertility Dx and RxInfertility Dx and Rx
Success in Success in DiagnosisDiagnosis
Success in Success in TherapyTherapy
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Improved SuccessImproved Success
Better Diagnostics: fewer cases of unexplained Better Diagnostics: fewer cases of unexplained infertility.infertility. PCOSPCOS Ovulatory dysfunctionOvulatory dysfunction ImagingImaging Endometrial functionEndometrial function
Better Therapy: Higher overall success.Better Therapy: Higher overall success. SurgerySurgery Ovulation inductionOvulation induction IVF and related proceduresIVF and related procedures
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Aging PopulationAging Population
Age at marriageAge at marriage Age at first pregnancyAge at first pregnancy
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Age and FertilityAge and Fertility
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Age and IVF SuccessAge and IVF Success
IVF success: Effect of age and number of eggs
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The aging Ovary (and testicle)The aging Ovary (and testicle)
Decreased Ovarian Reserve (DOR)Decreased Ovarian Reserve (DOR) Lower conception ratesLower conception rates Higher rates of pregnancy lossHigher rates of pregnancy loss Higher incidence of Congenital defectsHigher incidence of Congenital defects
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Menopausal ovary
The Aging OvaryThe Aging Ovary
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Normal ovary
Fewer eggsDecreased egg quality
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A Practical Approach to the A Practical Approach to the aging ovaryaging ovary
Aggressive Diagnosis Aggressive Diagnosis and therapyand therapy
Expand Treatment Expand Treatment optionsoptions
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Diagnosis: The evaluation Diagnosis: The evaluation cyclecycle
Baseline hormonesBaseline hormones Ovulation profileOvulation profile Imaging: HSG, Sono-Imaging: HSG, Sono-
HSG, MRIHSG, MRI Semen AnalysisSemen Analysis Other: Genetic Other: Genetic
studies, immune studies, immune workup etcworkup etc
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Therapy-The aging ovariesTherapy-The aging ovaries
IVFIVF Pre-implantation Genetics (PGD)Pre-implantation Genetics (PGD) Egg DonationEgg Donation Egg Freezing/Ovarian tissue freezingEgg Freezing/Ovarian tissue freezing
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In Vitro Fertilization and In Vitro Fertilization and Embryo Transfer (IVF-ET)Embryo Transfer (IVF-ET)
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IVFIVF
Intra-cytoplasmic Sperm injection (ICSI)Intra-cytoplasmic Sperm injection (ICSI) Assisted zona Hatching (AZH)Assisted zona Hatching (AZH) Day 4-5 transfer and improved culture Day 4-5 transfer and improved culture
mediamedia Cryopreservation of embryosCryopreservation of embryos
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ICSIICSI• Poor sperm quality
• Zona Pellucida hardening
• Poor egg-sperm interaction
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Assisted Zona Hatching Assisted Zona Hatching (AZH)(AZH)
Improved Implantation
Zona Hardening
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Improvements in culture Improvements in culture conditions- Blastocyst transferconditions- Blastocyst transfer
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PGDPGD
Micromanipulation: remove a single Micromanipulation: remove a single blastomere from an 8-cell embryo without blastomere from an 8-cell embryo without damaging the embryodamaging the embryo
Genetic testingGenetic testing FISHFISH PCRPCR
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PGD: Fluorescent In Situ PGD: Fluorescent In Situ Hybridization (FISH)Hybridization (FISH)
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PGD- IndicationsPGD- Indications Chromosomal Chromosomal
disordersdisorders Single gene defects Single gene defects
(CF, Thalassemia, (CF, Thalassemia, Sickle cell disease)Sickle cell disease)
Recurrent pregnancy Recurrent pregnancy lossloss
Repeat IVF failuresRepeat IVF failures Severe male factorSevere male factor
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How is PGD performed?How is PGD performed?
Ovarian StimulationIVF
Blastomere Biopsy on Day 3
Genetic AnalysisTransfer of
Unaffected Embryo
OutcomeChromosomally Normal Baby
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PDG- Clinical outcomesPDG- Clinical outcomes
Identify normal embryosIdentify normal embryos Fewer embryos to transferFewer embryos to transfer Know when not to transferKnow when not to transfer Reduce pregnancy loss and anomaliesReduce pregnancy loss and anomalies
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Third Party ReproductionThird Party Reproduction
Egg donationEgg donation Embryo donationEmbryo donation Gestational surrogacyGestational surrogacy
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Egg Donation: IndicationsEgg Donation: Indications
Ovarian Failure.Ovarian Failure. Poor egg quality.Poor egg quality. Recurrent IVF failure.Recurrent IVF failure. Recurrent pregnancy lossRecurrent pregnancy loss Genetic defects precluding normal pregnancy.Genetic defects precluding normal pregnancy.
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The Egg Donation ProcessThe Egg Donation Process The process involves IVF.The process involves IVF. The resulting offspring will carry genetic The resulting offspring will carry genetic
material of the material of the donordonor and the and the male partnermale partner..
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The Egg Donation ProcessThe Egg Donation Process
Donor and recipient cycles are Donor and recipient cycles are synchronizedsynchronized..
Eggs taken from the donor after Eggs taken from the donor after ovarian ovarian stimulationstimulation..
Eggs are fertilized with Eggs are fertilized with recipient partner’s recipient partner’s spermsperm..
Embryos transferred to the uterus of a Embryos transferred to the uterus of a hormonally primed recipienthormonally primed recipient..
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Egg Donation: The ProcessEgg Donation: The Process
DonorDonor Synchronize cycle with Synchronize cycle with
recipientrecipient Ovarian stimulationOvarian stimulation Egg retrievalEgg retrieval
RecipientRecipient Synchronize cycle with Synchronize cycle with
donordonor Preparation of the Preparation of the
uterusuterus FertilizationFertilization Embryo transferEmbryo transfer
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Egg Donation: The donorsEgg Donation: The donors Donor recruitment: Who are the donors?Donor recruitment: Who are the donors? Donor Screening: How are they tested?Donor Screening: How are they tested? Donor matching: How do I pick a donor?Donor matching: How do I pick a donor?
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Egg Donation: The recipient Egg Donation: The recipient couplecouple
Medical ScreeningMedical Screening The Mock cycleThe Mock cycle
Psychological issuesPsychological issues Legal IssuesLegal Issues Ethical concernsEthical concerns: Disclosure : Disclosure
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Cryopreservation of embryos, Cryopreservation of embryos, eggs and ovarian tissueeggs and ovarian tissue
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IVF and Cryopreservation of IVF and Cryopreservation of EmbryosEmbryos
AdvantagesAdvantages:: Well established Well established
method. method. High success.High success.
DisadvantagesDisadvantages:: More difficult for More difficult for
unmarried women.unmarried women. Limited number of Limited number of
embryosembryos Delay in cancer therapy Delay in cancer therapy
due to the IVF process.due to the IVF process. Contraindication to Contraindication to
ovarian stimulation in ovarian stimulation in Estrogen sensitive Estrogen sensitive tumors.tumors.
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Egg FreezingEgg Freezing-Applications-Applications
Ovarian malignanciesOvarian malignancies Ovarian surgeryOvarian surgery AgingAging Egg banksEgg banks
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Egg FreezingEgg Freezing
AdvantagesAdvantages No need for ovarian No need for ovarian
stimulationstimulation No need for No need for
fertilizationfertilization Enables preservation Enables preservation
of eggs prior to of eggs prior to surgery chemo or surgery chemo or agingaging
DisadvantagesDisadvantages Lower survivalLower survival Possible damage to Possible damage to
mitotic spindlemitotic spindle Still experimentalStill experimental
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Egg Freezing At NEFIEgg Freezing At NEFI
Technique: Technique: New Advancements in New Advancements in cryopreservation.cryopreservation.
CandidatesCandidates Cancer and chemoCancer and chemo Egg bankEgg bank Preservation of reproductive potentialPreservation of reproductive potential
Age <38Age <38 FSH <12FSH <12
Good Survival/fertilization and embryo Good Survival/fertilization and embryo developmentdevelopment
Ready to launchReady to launch
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SummarySummary
Technology is developing rapidlyTechnology is developing rapidly Ovarian aging is a major factorOvarian aging is a major factor ART is limited but can offer help for the ART is limited but can offer help for the
aging ovary.aging ovary.
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HoweverHowever
Don’t Delay.Don’t Delay. Discuss all options early.Discuss all options early. Consult or refer if needed.Consult or refer if needed.
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CT State Mandate for Fertility CT State Mandate for Fertility TherapyTherapy
BenefitsBenefits DiagnosticsDiagnostics Ovulation therapy/inseminations X3 Ovulation therapy/inseminations X3 IVFx1IVFx1
LimitationLimitation Age <40Age <40 Look Back: Look Back: Time with current carrier: at least one yearTime with current carrier: at least one year Excludes self insurers, religious organizations etc.Excludes self insurers, religious organizations etc.
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Return to referring MDReturn to referring MDDelay in referralDelay in referral
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Return to referring MDReturn to referring MDLength of clomid therapy by PMDLength of clomid therapy by PMD
Results (IV)
55%
53%
25%
0%
10%
20%
30%
40%
50%
60%
No CC 1-4 CC cycles >4 CC cycles
128/232 37/69 2/8
% of patients whoreturned to ROB
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A Team ApproachA Team Approach
The primary caregiverThe primary caregiver The infertility specialistThe infertility specialist
PhysicianPhysician Nurse/midwife/NPNurse/midwife/NP LaboratoryLaboratory Emotional counseling and supportEmotional counseling and support
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We would like to We would like to thank our sponsor:thank our sponsor:
OrganonOrganon
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Thank you for coming.Thank you for coming.
Gad Lavy, M.D. F.A.C.O.G.Gad Lavy, M.D. F.A.C.O.G.
New England Fertility InstituteNew England Fertility Institute
Lifeline CryogenicsLifeline Cryogenics