Assisted reproductive technologies (art)

Assisted reproductive technologies (art)

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  Assisted Reproductive Technologies (ART) NIKMUHAMAD ARIFF BIN MOHD AZMI BMS 13091713
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  Definition • Treatments orprocedures that include the handling of human eggs and sperm or embryos for the purpose of establishing a pregnancy
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  The first successfulIVF case was in 1978 when a British woman delivered a baby called Louise Brown in 28 July 1978 in Oldam in England by Caesarean section.
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  Patient Selection (Ideal) Age< 35 years Presence of ovarian reserve Normal seminogram (husband) Screened negative for HIV & hepatitis Normal uterine cavity
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  Principal Steps ofAn ART Cycle Down regulation using GnRH agonist Controlled ovarian hyperstimulation (COH) Monitoring of follicular growth Oocyte retrieval Fertilization in vitro (IVF, ICSI, GIFT) Transfer of gametes or embryos Luteal support with progesterones
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  1) GnRH Analoguesfor Down regulation Currently most ART procedures involve the use of GnRH agonists • GnRH agonist therapy used for down regulation of pituitary to prevent premature LH surge • GnRH agonist therapy is continued either subcutaneously or intranasally during the gonadotropin treatment phase • GnRH antagonists are currently tried along with gonadotropin stimulation to prevent premature LH surge or premature ovulation. Cetrorelix & Ganirelix are the available drugs.
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  Natural Cycle In thefirst case, Steptoe & Edwards (1978) achieved success from collecting the oocyte from a natural cycle, 36 hours after the onset of LH surge. Compared to stimulated IVF cycles, it has a few advantages. Requires no medication. Less cost. Minimizes complication(multiple pregnancy). High cycle cancelation rates due to premature LH surge. Low success rate. Advantages of induction of superovulation are: 1. Improved quality of oocyte. 2. Timing of ovulation can be controlled. 3. Suited to all cases of ovulatory dysfunction.
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  2) Controlled Ovarianhyperstimulation (COH) Gonadotropin stimulation is begun once pituitary down regulation is achieved (serum E2 < 40 pg/mL and no ovarian follicles are seen > 10 mm on TVS). Exogenous gonadotropins for (uFSH, rFSH, HMG) ovarian stimulation are used. The drug regimens used differ in each centre.
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  3) Monitoring ofFollicular Growth The follicular growth response is monitored by 1. Cervical mucus study 2. Sonographic measurements of the follicles (17-18 mm) 3. Serum estradiol estimation (> 250 pg/mL)
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  4) Oocyte RetrievalOocyte retrieval is done aseptically through vaginal route under ultrasound guidance. With the development of vaginal transducers, vaginal needle aspiration is done about 36 hours after hCG administration but before ovulation occurs. IV analgesia and sedation (Propofol) is adequate in most of the cases. The oocyte is readily recognizable as a single cell surrounded by a mass of cumulus cells. After recovery, the oocytes are maintained in culture in vitro for 4-6 hours.
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  5)Fertilization (In Vitro) Thesperm used for insemination in vitro is prepared by the wash and swim-up or density gradient centrifugation (preferred) technique. Approximately 50,000 – 100,000 capacitated sperm are placed into the culture media containing the oocyte within 4-6 hours of retrieval. The eggs may demonstrate signs of fertilization when examined 16-18 hours after insemination (presence of two pronuclei in the presence of a second polar body) Sperm density and motility are the two most important criteria for successful IVF. The semen is collected just prior to ovum retrieval.
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  6) Embryo TransferThe fertilized ova at the 6-8 blastomere stage are placed into the uterine cavity close to the fundus about 3 days after fertilization through a fine flexible soft catheter transcervically. Not more than 3 embryos are transferred per cycle to minimize multiple pregnancy. The process of transfer should be accurate, atraumatic and aseptic. Excess oocytes and embryos can be cryopreserved for future use. This will reduce the cost of ovulation stimulation as well as the risk of ovarian hyperstimulation.
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  7) Luteal Phasesupport Is maintained with progesterones. It is started on the day after oocyte retrieval. hCG is given supplemental doses (1,500-2,500 IU). Micronized progesterone 200mg thrice a day oral or as vaginal suppository(preferred) or progesterone in oil injection 50mg IM daily is continued for about 14 days. By this time diagnosis of pregnancy by estimation of β-hCG (quantitative value) is possible. Result : The overall live birth rate varies from 32.7 percent per oocyte retrieval.
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  Prognostic factors forIVF-ET Maternal age Ovarian reserve Indication of IVF & past reproductive success Presence of hydrosalpinges Fibroid uterus Smoking
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  References D C Dutta’sTextbook of Gynaecology 6th Edition https://www.nhs.uk/Conditions/IVF/Pages/Introducti on.aspx https://www.surrogacyuk.org/about_surrogacy http://www.babycenter.com/0_fertility-treatment- http://americanpregnancy.org/infertility/gamete-i Web